Benign anorectal diseases
Symptoms Bleeding Pruritus Discharge Fecal incontinence Diarrhea Constipation False need to defecate
Examinations Clinical exam Anuscopy Rectosigmoidoscopy Endosonography MRI Manometry MR Defecography
Proctological examination
High resolution anoscopy For patients with increased risk of anal cancer and abnormal anal cytology 1. MSM-HIV positive 2. HIV patients 3. Transplant patients 4. Women with a history of lower genital tract dysplasia
High resolution anoscopy-for detection of high grade squamous intraepithelial lesions An anoscope is inserted and a colposcope is used for the examination of the squamocolumnar junction, the transformation zone and the perianal skin Application of acetic acid 3% or 5% Lugol iodine solution
HSIL Flat or thickened Often with vascular changespunctuation or mosaic pattern Acetowhite Poor uptake of Lugol
High resolution anoscopy
High resolution anoscopy-lugol
High resolution anoscopystaining with Lugol
Hemorrhoids
Hemorrhoids Diagnosis and treatment are based on symptoms rather than appearance Therapy should be guided by two principles 1. Colonic or rectal disease must be excluded 2. Asymptomatic hemorrhoids should not be treated
Treatment of hemorrhoids Conservative management Endoscopic treatment Surgical treatment
Pay attention-defecation habit-3 errors Insistence in having at least one bowel movement daily Neglect of first urge to defecate in the morning Insisting on trying to pass the last portion of stool from the rectum to anal canal, to prevent the peristence of discomfort
Complication and treatment Thrombosis
Endoscopic treatment of hemorrhoids Hemorrhage
Rubber band ligation Placing a rubber band ar the base of a hemorrhoid In second degree hemorroids At the anorectal junction immediately above the internal hemorrhoid Application that is too low, near the dentate line and too deep induce pain!!! Only one to two areas should be banded at a time to prevent severe discomfort New session after 3-6 weeks Low rate of complication: liver abscess, clostridial sepsis, soft tissue infections andbacterial sepsis or toxemia
Infrared coagulation Thermal necrosis followed by ulceration, which heals by cicatrisation in 2-3 weeks The scar fixes the mucosa to the underlying tissue and prevents prolapse Two sessions: coagulate at 2, 4, 8 and 10 o clock and 3, 6, 9, 12 o clock Postoperative pain and secondary bleeding are rare Cure at 12 months can be achieved in 75% of first and secind degree hemorrhoids 15% recurrence in 3 years
Skin tags Usually not symptomatic Folds of skin
Hypertrophic anal papille
Anal fissures Acute-mostly heal spontaneously Chronic-persistence beyond 6 weeks, morphologically-presence of visible transverse internal anal sphincter fibers at the base of the fissure Associated signs in chronic fissures: indurated edges, a sentinel pile and a hypertrophied anal papilla
Typical Atypical or multiple Posterior midline 75% Anterior midline 25% Posterior and anterior 3% Crohn Disease Trauma Tuberculosis Syphilis AIDS Anal carcinoma Anal fissures
Treatment of anal fissures Nitric oxide donors-glyceril trinitrate 0.2% up to 8 weeks Calcium channel blockers topical nifedipine, topical diltiazem (heal between 48 and 75% of fissures that fail GTN Botulinum toxin A-injection into the internal anal sphincter-safe drug in short and medium therm Surgical therapies
Abscesses and anal fistulas Anorectal abscesses frequently result in more or less complex and extensive fistulous tracts The two pathologies should be regarded as the same condition Primary septic lesions have a cryptoglandular origin-90% of fistulas
Symptoms Discomfort, perianal pain and swelling-aggravating by sitting,walking and defecation Sometimes minor anal bleedingand discharge if small amount of pus Superficial cellulitis Fever, chills, malaise
Diagnosis of abscess and fistulas Clinical exam Endosonography MRI
Sometimes anorectal examination with a rigid instrument To identify the anal crypt responsible for the infection To determine the prsence of underlying septic or inflammatiry proctitis To look for a perforated anorectal cancer
Classification of anal abscesses
Fistula
Anal abscess
Anal fistula
Seton drainage
Condyloma acuminata Due to HPV infection Some serotypes /high potential of malignancy HPV 16 and 18!!! Perianal and/or intraanal-examination of anal canal!
Condyloma acuminata high resolution anoscopy( a.acetowhitening b.treatment with trichlor acetic acid 85%)
Condyloma planum
Therapy Podophyllin diluted to 15-20%-when the lesions are few and small Cryosurgery, electrosurgery, laser treatment Clinical trials with interferons(alpha, gamma) Local immunostimulation with imiquimod
Perianal hidrosadenitis suppurativa
Perianal hidrosadenitis suppurativa Chronic recurrent inflammatory disease of apocrine glands, adjacent anal canal skin and soft tissues Sometimes associated with Crohn disease