Anal fissure

Anal fissure -It is elongated ulcer (split) which occurs in the lower half of the anal canal - always in the mid line - 90% posterior 10% anterior - but in female , 60% posterior 40% anterior -The fissure could be lateral, if it is due to inflammatory bowel disease - more in female than male - uncommon in elderly A etiology 1 -In constipation, the hard fecal material injury the posterior wall of the anal canal below the dentate line, here the epithelium is less supported by muscle and it is more liable to injury and this lead to tear 2- Inflammatory bowel disease 3- anal stenosis after operation for haemorrhoid 4- sexually transmitted disease

Pathology; There are two types of fissure , acute and chronic type acute fissure - superficial tear in the lower half of the anal canal in midline usually posteriorly - The tear might be up to the dendate line - There is little edema and inflammatory reaction - The pain caused by the fissure cause spasm of the internal sphincter muscle which prevent healing

- chronic fissure, if the acute fissure is not healed , it will change to the chronic which is characterized by 1- the margins become indurated 2-fibrosis in the underling internal sphincter might lead to anal stenosis 3- anal papilla at upper end of fissure 4- edematous skin tag at lower end of fissure sentinel pile 5- anal infection 6-there is picture of inflammtory bowel disease, if the fissure is due to it.

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Acute anal fissure

Chronic anal fissure

Chronic anal fissure

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Clinical feature 1- pain , sharp, agonizing , starting during defecation and may continue to few hours after it 2- constipation patient avoid defecation due to the pain 3- bleeding streak of blood at surface of the stool 4- slight anal discharge , and pus if there is infection 5- reflex symptom such as pain along thigh, dysmenorrhea, burning of micturition - In acute fissure digital rectal examination can not be done - in chronic fissure can be done after an anesthetic jelly application

Differentail diagnosis 1- early ca. of the anus 2- multiple fissure in case of inflammatory bowel disease , sexually transmitted disease and sexual abuse 3- TB. 4- proctalgia fugax is sever pain arising in the rectum in irregular time with out organic cause , may be due to cramp in the pubo-coccygeus muscle - Biopsy indicated in atypical presentation of fissure


Treatment The aim is to relieve the spasm of the internal sphincter to give chance for fissure to heal A- conservative treatment It is first line of treatment but if not respond surgery is indicated Medical therapy is effective in most of acute fissures, but it will heal only 50-60% of chronic fissure (schwartz) 1- high fiber diet some time even laxative 2- local anesthetic ointment (lignocaine)

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3- chemical sphincterotomy by - glyceyl trinitrate ointment (o,2%) , cause relaxation of internal sphincter and vascular dilation which improve the blood supply and enhance healing but it cause headache - Newer agents, such as arginine (a nitric oxide donor) and topical bethanechol (a muscarinic agonist), has less side affect have also been used to treat , - oral and topical diltiazem it is Calcium canal blocker - Botulinum toxin. 4- analgesic 5-warm water bath have soothing affect

B- operative treatment if the pain is not relieved or fissure not improved surgery is indicated The type operation recommended is 1- lateral internal sphinsterotomy , - it is to divide the lower part (bout 30%) of internal sphincter - usually left side , at a3 o'clock, in lithotomy position - under under general or local anesthesia 2- fissurectomy if fissure is heavily fibroses with skin tag bitter to do fissurectomy, to excise the fissure, anal papilla and sentinel pile. 3- anal dilation four finger dilatation under general anesthesia , especially for acute fissure , but now days rarely used due to it`s complication(incontinence)


Haemrrhoids(pile) In Greek haema means blood and rhoos is flowing In Latin pila means ball Morbid anatomy The terminal branches of superior rectal vessels form assort of vascular plexus under the epithelial lining of the anal canal called anal cushions which arranged at 3,7,11 o'clock around the circumference of anal orifice at lithtomy position haemorrhoids , is congestion ,enlargement and prolapsed of anal cushion .
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There are two type of haemorrhoid 1- internal haemorrhoid ;affection of internal haemorrhoid plexus above dentate line produce internal haemorrhoid and covered by mucous membrane and bright red or purple in color 2- external haemorrhoid ; affection of the external haemorrhoid plexus below the dendate line produce external haemorrhoid and covered by skin

3-interno-external haemorrhoid if both occur. Internal haemrrhoid it also include interoexternal hemorrhoid some times there is small haemorrhoid between the main haemorrhoid it called daughter haemorrhoid and the main haemorrhoid called mother haemorrhoid


haemorrhoid

haemorrhoid

haemorrhoid


Aetiology haemorrhoid is primary if there is no definite cause and it is secondary hemorrhoid if there is a definite cause, which is rare and may occurs with 1- pregnancy 2 - carcinoma of the rectum In primary haemorrhoids 1- genetic factor more common in certain family 2- chronic straining in defecation


3- anatomical factor a - anal anal cushion is in loose unsupported connective tissue, aging cause degeneration of the elastic tissue might result in hemorrhoid b - tributaries of the anal cushion pass through rectal muscle, contraction of this muscle at defecation affect hemorrhoid formation c - no valve in the portal system and in portal hypertension there is increase hydrostatic pressure

Clinical feature 1- bleeding per rectum ,most common - occur at straining , - at end of defecation - fresh bright red - jet of droops separated from stool 2- prolapse the vascular cushion enlarge and descend below the dendate line - hemorrhoid classified according the prolapse and the treatment depend on the degree of prolapse -1st degree pile no prolpase only enlarge cushion bleeding might be present -second degree , it prolapse only at defecation , but spontaneously reduce - third degree , it prolapse during defecation and the patient reduce it manually - fourth degree , there is permanent prolapse of pile

3- anal discharge and pruritus in 3rd and 4th degree 4-pain and discomfort if there is complication Examiation - is essential to exclude malignancy - internal hemorrhoid is impalpable by digital rectal examination - it need proctoscope to sea the hemorrhoid - It is necessary to do sigmoidoscope to exclude the rectal tumor


complication 1- profuse hemorrhage 2- anemia 3- strangulation of prolapsed hemorrhoid by external sphincter it become tense red painful and strangulation lead to thrombosis , ulceration and gangrene 4-suppuration due to infection of thrombosed pile 5 - fibroses some time thrombosed pile converted to fibrous tissue 6-portal pyaemia due to infected thrombosed pile


Haemorrhoid - gangrane

* * Complications

* * Complications


Treatment it depend on the degree of haemorroid and symptom ,as general idea , the line of treatment is 1-for 1st and 2nd degree treatment is - conservative - injection sclerotherapy - Rubber band ligation - photocoagulation 2- for 3rd and 4th degree surgery is recommended 3- for secondary pile deal with the cause

Conservative treatment (symptomatic treatment) Indication in early pile - avoid constipation and staining at defecation - high fiber diet - small dose of laxative - suppositories that contain decongestants

Sclerotherapy - Indication bleeding 1st and 2nd pile - Idea to inject irritant to the submucosa at pedicle of hemorrhoid ,with out anesthesia and these will cause fibrosis and pull the cushion of pile - 3-5ml of 5%phenol in almond oil injected to the submucosa of pedicle - three hemorrhoid can be injected at the same time - can be repeated once or twice after 2-weaks or more Complication of sclerotherapy 1-seve pain if injected at low position under anoderm 2- necrosis of mucosa 3-allergy 4-submucous abscess


Rubber band ligation - Indication for 2nd and early 3rd degree - the idea is to put tight elastic rubber band around the pedicle of the hemorrhoid and these lead to ischaemic necrosis and later separation - method it is done in clinic and no need anesthesia

* * Banding Treatment (Barron)

Infrared photocoagulation - Indication 2nd and early 3rd degree of hemorrhoid - the idea that infrared rays can cause tissue temperature of 100 c which produces area of coagulation necrosis - the dead tissue separate after 10-14 days leaving granulation tissue lined by ulcer - it is painless and affective method and can be done in clinic


* * Cryosurgery like photocogulation By liquid nitrogen extreme cold (-196 degree C)coagulation necrosis of the piles..

Surgical treatment ;haemorrhoidectomy - indication, 3rd and 4th degree haemorrhoid - the idea is to excise the hypertrophied vascular cushions with the overlying redundant skin method - need rectal preparation by enema - done under general or spinal anesthesia - prolapsed pile dissected up to the pedicle , ligated and excised - all the hemorrhoid dealled with at the same time and island of the mucosa leaved between excised hemorrhoid to ovoid post operative stenosis

- post operative treatment 1- strong analgesia 2- laxative 3- warm bath

* * HAEMORRHOIDSHAEMORRHOIDECTOMY

ligation and Excision: (B) Transfixion of the pedicle; (C) Ligation.

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Complication of hemorrhoidectomy 1- haemorrhage due to bad homeostasis or slipping of suture, some time very sever to that patient need to taken to operative room and to ligate the bleeding vessel under general anesthesia 2- retention of urine , it is common due to pain ,treatment need pain killer, warm bath , get out of bed , if these fail catheterization is advised 3-anal stricture can be avoided by leaving mucosal island and post operative digital examination after two weeks of surgery if there is stenos is anal dilatation

4- recurrence due to enlarged daughter pile , can be treated by injection 5-fissure, cutaneous wound is not healed and lead to the fissure formation and need treatment 6- incontinence


Treatment of proplasd strangulated haemorrhoids A - surgery (haemorrhoidectomy) under cover of antibiotic If diagnosed early B- conservative treatment If the diagnosis is delayed, the tissue is friable and there is might be secondary infection and there for the following measures advisable later on to do proper surgery 1-rest in bed 2-antibiotic 3- analgesic 4-warm bath 5- decongested ointment, local anesthetic and local compresses C - Anal dilation and reduction of the prolapsed hemorrhoid

Acute perianal haematoma (thrombosed external haemorrhoid) Pathogenesis - it is due to rapture of dilated anal vein due to straining at defecation, coughing, lifting heavy weight. - These lead to hemorrhage to subcutaneous tissue usually at lateral position - it cause sever pain clinical picture , - pain, tense , tender, bluish swelling covered by smooth shining skin Fate haematoma - usually resolved , - might be suppurate, ulcerate and thrombous extruded - might be fibrosed and give rise to cutaneous tag Treatment - if patient come early with in36-hours surgery - if late conservative


Treatment If patient present early with sever pain the haematoma can be taken out under local anasthesia other wise conservative treatment