Anorectal abscess

Anorectal abscess it is either primary or secondary A- Primary anorectal abscess due to infection of the anal gland (90%) or the skin gland B- Secondary anorectal abscess is due to 1-inflammtory bowel disease 2- specific infection such as TB 3-anorectal carcinoma 4-infection of the perianal hematoma, thrombosed pile and anal fissure

The anal gland is situatted at intersphincter spac at the level of the dendate line and it open to the anal crypt (the crypt of Morgagni) The infection of the anal gland leads to formation of an intersphincteric abscess which may spread to 1- down ward , it form perianal abscess 2- out ward, it form ischiorectal abscess 3- inward , it form sub mucous abscess - the infection is mainly by Ecoli (60%), staph.aureus(23%) - other microorganisms like bacteroides, sterptococcus and proteus also isolated

Classifiction and clinical features 1- perianal abscess 60% a - usually due to down spread of intersphincteric infection, or infection of perinal hematoma b - abscess is subcutaneously near the anal orifice c - pain and constitutional symptom is not sever 2- ischiorectal abscess 30% a -it is due to lateral extension of the interspincter infection b - high fever and sever constitutional symptom c - Throbbing pain d - Large , indurate, tender swelling e - it will extend to post sphincter and involve other side to form horse shoe abscess


3- submucous 5% a- it lies submuouslly above dendate line b- patient has sever pain and fever c - tender boggy swelling by digital examination 4-pelvirectal abscess 5% a -it locate between peritoneum and upper surface of the levator ani muscle b- pelvic abscess secondary to perforated appendix or injury of levator ani in the operation for ischiorecral abscess is might be the cause


Treatment - Urgent surgery - cruciate incision and drainage under general anassthesia - daily dressing and packing - antibiotic - warning the patient that he might be develops anal fistula

* * ANO-RECTAL ABSCESSES

A- perianal B- ischiorectal C- submucous D- pelvirectal

* * Ischiorectal abscess

* * ANO-RECTAL ABSCESSES

Drainage of perinal abscess

* * Ischiorectal abscess

Fistula in ano - It is track , lined by granulation tissue, that connects deeply in the anal canal or rectum and superficially on the skin around the anus - It is usually results from an anorectal abscess which bursts spontaneously or opened inadequately - it continue to discharge - it seldom heal with out surgery due to reinfection from rectum

Pathology -The anal gland act as reservoir for infection - presence of internal opening allows recurrent activation of infection or reinfection from anal canal or rectum - fecal material might act as foreign body - underling specific disease might be present such as inflammatory bowel disease , tuberculosis - Some time multiple external opening with single internal opening

Classification Standard classification it is accorgind to the position of internal opening in relation to the anorectal ring 1-low fistula , most common ,the internal opening below the the anorectal ring usually at the level of dentate line 2- high fistula very rare , the internal opening above the anorectal ring

* * FISTULA-IN-ANO  Standard classification

Low level: 1 .Subcutaneous 2.Submucuous 3. Low anal High Level: 4. High anal 5. Pelvirectal



New classification (Parks classification) -According to the course of the tract and it`s relation to the anosphincter muscle Almost all anal fistulae have their internal opening in the anal canal at the level of dentate line communicating with an intersphincteric abscess cavity

we have four type 1- intersphincteric fistula, begin at dendate line , pass between external and internal sphincter to the perianal skin 2- transsphinceric, start ad dendate line and pass through both internal and external sphincter to ischiorectal fossa and skin, might have additional tract


3- suprasphincteris fistula, it start at dendate line and traverses upward through intersphincteric plain and pass entire external sphincter to ischiorectal fossa and open to skin 4 -extrasphincteric (supralevator) fistula it pass from rectum to the perineal skin through levator ani muscle and ischiorectal fossa, it also has other communication to the dendate line through both sphincter

Clinical features - history of perianal abscess - seropurulent anal discharges -Local soreness and pruritus ani - attacks of perineal pain due to recurrent abscess

Goodsall`s rule - the position of internal opening and the line of tract is determined by external opening of fistula - Take imaginary line between ischial tubersities passing through anal canal - if the external opening anterior to this line , the internal opening is anteriorly ,on the same radius, having short direct fistulas tract - if the external opening posterior to this line , the internal opening is posteriorly in the midline

Examintion the finding in rectal examination are -Single or multiple opening near anal orifice - pus or fluid coming from opening - indurations of perineal skin - internal opening felt by digital examination and can be seen by proctoscope - probing under GA - radiography

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* * FISTULA-IN-ANO

Anal fistula

Anal fistula

Treatment The idea is to eradicate the sepsis and preserve the anorectal function 1- open the fistula tract 2-currete the tract 3-trim the edge to keep the tact open - The type of surgery is depended on the type of fistula

Intersphinecter fistula. - fistulotomy to interduce a prope in side the tract and divide on it and deroof the tract , usually the lower part of internal sphincters is divided it does not disturb the continence Tanssphinctric fistula - fistulotomy is to divide the the internal sphincter below the dendate line and superficial part of the external sphincter - might be cause temporary disturbance of continence

-Suprasphincter fistula - staged fistulotomy ,to ovoid incontinence 1-fistuletomy for lower part of fistula by dividing of internal sphincter up to dendate line 2-put a seton (ligature of silk nylon,or silastic tube)to remaining part of tract - tight intervally till the seton comes out - or after two weeks of application of seton, do fistulotomy by the guide of seton

* * FISTULA-IN-ANO Treatment of High-level Fistulas- seton

-Exrasphincteric fistla it is very complex - treat the cause - do proximal colostomy - do staging fisulotomy - close the colostomy after complete healing of fistula

* * Special Clinical Types of Fistulas-in-ano

1. tuberculous proctitis : - About 2-3% of fistulas-in-ano are tuberculous - there is induration of the area ,discoleration of the skin with watery discharge - Histopathological examination confirms the diagnosis of tuberculous. - it respond to anti-tuberculous drugs alone 2. Fistulas with many external openings may arise from, inflammatory bowel disease, Granulomatous infections bilharziasis, and lymphogranuloma inguinale, biobsy need to confirm the diagnosis

* * 3. Carcinoma arising within Perianal Fistulas: - Colloid carcinoma may complicate the fistulae or the colloid carcinoma of the rectum is liable to be complicated by perianal fistulas. Both adenocarcinoma and squamous-cell carcinoma are known to arise within chronic fistulous tracks.

Anal Canal and Perianal Tumors Cancers of the anal canal are uncommon and account for approximately 2% of all colorectal malignancies. Neoplasms of the anal canal can be divided 1-affecting the anal margin (distal to the dentate line) , its lymphatic drainage to the inguinal node 2- affecting the anal canal (proximal to the dentate line). Its lymphatic drainage to the superior rectal and to pre aortic lymph node



A-Anal Intraepithelial Neoplasia AIN (Bowen's Disease) Bowen's disease refers to squamous cell carcinoma in situ of the anus. Pathology - carcinomas in situ and high-grade squamous intraepithelial dysplasia - AIN is a precursor to an invasive squamous cell carcinoma (epidermoid carcinoma). Clinical feature - AIN may appear as a plaque-like lesion, - AIN is associated with infection with the human papilloma viruse especially HPV types 16 and 18.,in homosexual men., -The incidence of both AIN and epidermoid carcinoma of the anus has increased dramatically among HIV-positive patient .

. Treatment treatment of AIN is aimed at either to resection or ablation. - Extensive resection with -flap closure may occasionally be required. - Because of a high recurrence and/or reinfection rate, these patients require extremely close surveillance

B-Epidermoid Carcinoma Epidermoid carcinoma of the anus includes squamous cell carcinoma, cloacogenic carcinoma, transitional carcinoma, and basaloid carcinoma. Clinical features -The clinical behavior and natural history of these tumors is similar. -Epidermoid carcinoma is a slow-growing tumor - usually presents as an anal or perianal mass. -Pain and bleeding may be present


Treatment it depend on the site of lesion, type of tumor and extension 1- epidermoid carcinoma of the anal margin may be treated by wide local excision (at least2.5cm from tumor) with out resecting the anal sphincter. .


2- Epidermoid carcinoma occurring in the anal canal or invading the sphincter cannot be excised locally - first-line of therapy chemoradiation, (combination of chemotherapy and (radiotherapy - More than 80% of these tumors can be cured by using this regimen. - examine the patient after 4-6 weeks , if there is obvious remaining tumor, abdominoperineal resection needed. -Recurrence after radiation also requires radical resection (abdominoperineal resection). -Metastasis to inguinal lymph nodes is a poor prognostic sign and need radical groin dissection

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D-Adenocarcinoma 1-adenocarcinoma of the anus is extremely rare 2-usually represents downward spread of a low rectal adenocarcinoma. 3-Adenocarcinoma may occasionally arise from the anal glands or may develop in a chronic fistula. Treatment - Radical resection (abdominoperineal resection) with or without adjuvant chemoradiation is usually required



E-Extramammary perianal Paget's disease - is adenocarcinoma in situ arising from the apocrine glands of the perianal area.. Treatment Wide local excision is usually adequate


F-Melanoma - Anorectal melanoma is rare, comprising less than 1% of all anorectal malignancies and 1 to 2% of melanomas. - prognosis is poor. Overall 5-year survival is less than 10%, - present with isolated local or locoregional disease Treatment by wide local excision. Or by radical resection (abdominoperineal resection [APR]) according to the extend of disease - The addition of adjuvant chemotherapy, biochemotherapy, vaccine, or radiotherapy may be of benefit in some patients


Fecal incontinence - is the inability to control bowels. or stool may leak from the rectum unexpectedly. - More than 6.5 million Americans have fecal incontinence. - It affects people of all ages--children as well as adults. but more common in older - more in female than male

Continence The maintenance of fecal continence is as complex as the mechanism of defecation - Continence requires 1- adequate rectal wall compliance to accommodate the fecal bolus, 2- puborectalis, this muscle creates a "sling" around the distal rectum with defecation, this angle straightens 3 – internal anal sphincters these muscle are tonically active at rest 4 - external anal sphincter it is voluntary muscle 5 - hemorrhoidal cushions may contribute to continence by mechanically blocking the anal canal.

Causes 1-injury of anal sphincter - tear during normal vaginal delivery, or by forceps delivery, or episiotomy - surgical trauma, during surgery for high anal fistula and hemorrhoid 2- neurogenic - pudendal or sacral nerve injury, -in case of diabetic autonomic neuropathy , stroke , multiple sclerosis

3- loss of storage capacity of the rectum, in case of inflammatory bowel disease, post radiation, the rectal wall can not expanded 4-Abnormalities of the pelvic floor can lead to fecal incontinence. Which occurs in case of, rectal prolapsed, rectocele 5- diarrhea

Diagnosis -History and clinical assessment - procto and sigmoidoscopy - internal ultrasound - manometry, to detect rectal function, ,length of anal sphincter, and their strength - anal electromyography test for nerve damage - defecography, shows how much stool , the rectum can hold, and how well the rectum can evacuate the stool.

Treatment A - Conservative treatment for mild case 1-constipating agent and dietary manipulation to thicken the stool. avoid caffeine ,cured or smoked meat like sausage, 2-anal sphincter and pelvic floor exercise 3- evacuating the bowel completely at morning by glycerin suppository


B- Surgical treatment 1 - repair of divided sphincter 2 - rectopexy for rectal prolapse will restore 50% of incontent cases due to rectal prolapse 3- graciloplasty , gracilus muscle transported around anal canal and stimulated electrically by pacemaker 4 - artificial anal sphincter , inflated silastic cuff around anal canal , deflated when fecal evacuation required 5- colostomy