常见肛周疾病commonanorectalppt课件

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1、Common Office Anorectal Problems,Sandra J. Beck, M.D., FACS, FASCRS Associate Professor of Colon and Rectal Surgery University of Kentucky Medical Center,Disclosures,None,Benign Anal Rectal Disease,Anatomy of the anal canal and perianal spaces Benign Anal Rectal Disease Abscess and Fistula Fissure H

2、emorrhoids,Overview of Anatomy,Anatomy Pelvic and Perirectal Spaces Anatomy of Anal Canal,Retrorectal Space,Waldeyers Fascia,Supralevator Space,Levator Ani Muscle,Deep Postanal Space,Superficial Postanal Space,Peritoneum,Levator Ani m.,Puborectalis m.,Deep External Sphincter m.,Internal Sphincter m.

3、,Transverse Septum,Supralevator Space,Ischioanal Space,Intersphincteric Space,Perianal Space,ANAL CANAL,ANAL CANAL,Anal Transitional Zone,Column of Morgagni,Dentate Line,Anal Crypt,Anal Gland,Anoderm,Diagnosis and Treatment of Anorectal Abscess and Fistula-in-Ano,Anorectal Abscess Etiology,Cryptogla

4、ndular abscess Most common Infection in the glands at the dentate line Other causes Crohns and Ulcerative Colitis Tuberculosis and Actinomycoses Malignancy Foreign Bodies, Prostate Surgery or Radiation,Fistula Description,Clock description Does the anus tell time? Relies on description of patients p

5、osition: supine, lateral, prone and relative landmarks Anatomic description: more consistent Pubic bone defines anterior Coccyx define posterior Right and left *If terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly

6、 executed. Confucius 1,Tailbone,Right anterior,Right posterior,Left anterior,Left posterior,Right,Left,Pubic bone,There is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drained,Abscess Classification,Four Types Based on Space Invo

7、lved Perianal - 19-54% Intersphincteric - 20-40% Ischioanal - 40-60% Supralevator 2% or less,Most Common,Rare,Supralevator Abscess,Perianal Abscess,Ischioanal Abscess,Intersphincteric Abscess,Supralevator Space,Intersphincteric Space,Ischioanal Space,HORSESHOE ABSCESS,Anorectal AbscessTreatment of P

8、erianal and Ischiorectal Abscesses,Diagnosis - usually straightforward Erythema and Pain over affected area Fluctuance Treatment Incision and Drainage +/- Excision of small amount of overlying skin Initial packing for hemostasis Drainage catheter (Pezzer) or pack wound Attention to good hygiene and

9、control blood sugar Antibiotics if immunocompromised, obese or diabetic,Small Radial incisionShort distance from anus feel for soft spotPlace drain and trim avoids packingFollow up in 7-10 days to remove drain,Catheter Types,Pezzer catheter Solid mushroom top so stays in Less tissue ingrowth,Malecot

10、 Allows tissue ingrowth More painful to remove,Peri anal abscess - ? Antibiotics,Not usually indicated if there is adequate drainage Indicated for patients with: Obesity Diabetes Imunocompromised Extensive large abscess or recurrent abscess,Fistula-in-Ano,Definition abnormal connection between two e

11、pithelial surfaces. Classification: Parks: Defines fistula by course of tract Goodsalls rule Diagnosis Treatment Goals Options,How does patient present?,May have had a history of abscess History of Crohns disease May present at the same time as abscess Complain of intermittent increase in pain/swell

12、ing followed by spontaneous drainage Chronic localized area of irritation or ulcer “pimple near my anus keeps coming back”,Fistula-in-AnoGoodsalls Rule,Posterior,Anterior,Fistula in ano,Fistula in ano: Surgical disease,Refer to Colon and Rectal Surgeon or General Surgeon Reassure patient rarely canc

13、er, most do not need a colostomy If suspect Crohns Gain control of perianal sepsis Then complete full workup and staging Goals of therapy Get rid of the fistula/connection Preserve continence,Surgical Options,Primary fistulotomy Mainly for low, superficial fistula Risk of fecal incontinence Fibrin G

14、lue/Fistula Plug Utilizes substrate as scaffold to fill tract Does not involve cutting muscle Cutting or draining setons For deeper tracts that involve significant muscle Risk of fecal incontinence Rectal advancement flap Lateral internal fistula transection Newer procedure. No foreign substrate Cut

15、s fistula tract, not muscle,Fistula in ano,Fistula in ano,Fissure in Ano,Definition a painful linear ulcer situated in the anal canal and extending from just below the dentate line to the margin of the anus Overlie the lower half of the internal sphincter 73.5% are posterior 16.4% are anterior 2.6%

16、both anterior and posterior,Fissure in AnoPathogenesis,Acute fissure results from trauma to the anal canal most commonly from a large fecal bolus Secondary changes of chronic fissure include Sentinel pile or skin tag at the distal end Hypertrophied anal papilla-swelling, edema and fibrosis near the

17、dentate line Fibrosis of the internal sphincter at the base,Fissure with Sentinel Tag,Fissure with Sentinel Tag,Fissure in AnoPathogenesis,Perpetuating factors in chronic fissure Persistent hard bowel movement Abnormal high resting pressure in the internal anal sphincter Increased pressure in the sp

18、hincter causes a decrease in blood flow, preventing healing of the fissure,Fissure in AnoSymptoms,Pain is the main symptom Sharp, cutting or tearing during defecation Duration is few minutes to hours Bleeding bright red and scant Skin Tag Mucous discharge resulting in itching,Fissure in AnoDiagnosis

19、,Diagnosis often made on history alone Inspection gently spread the buttocks and the fissure becomes apparent Triad of chronic anal fissure Sentinel pile Hypertrophied anal papilla Anal ulcer,Fissure in AnoDifferential Diagnosis,Intersphincteric abscess Pruritus Ani Fissure from inflammatory bowel d

20、isease Carcinoma of the anus Infectious Perianal conditions Leukemic infiltration,Fissure in AnoCrohns Anal Fissures,Acute Fissure in AnoTreatment,Increase dietary fiber Local anesthetic to prevent spasm Nitroglycerin or Nifedepine Ointment Not commercially available Must be mixed by pharmacist Warm

21、 tub soaks 4-6 weeks of treatment,Chronic Fissure in AnoSurgical Treatment,Indicated on Chronic non-healing anal fissure and fissure that is refractory to medical therapy Lateral Internal Sphincterotomy Forces the muscle to relax V-Y Anoplasty flap Allow coverage of fissure with healthy tissue,Hemor

22、rhoids,What are they? Where are they? Why do they become symptomatic? Classification? How do you treat them? Can they be avoided?,HemorrhoidsWhat are they?,Specialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective

23、tissue Aid in anal continence,HemorrhoidsWhere are they?,Internal Hemorrhoids 3 major bundles left lateral, right anterior and right posterior Above the dentate line Blood drains into the superior rectal vessels then into the portal circulation External Hemorrhoids Below the dentate line Blood drain

24、s through the inferior rectal veins to the pudendal veins on into the iliac veins,HemorrhoidsSymptoms?,Chronic constipation Diarrhea Trauma to the hemorrhoids during defecation cause the most common symptoms Pain generally not “knife-like” Itching Burning Bleeding,HemorrhoidsClassification- Internal

25、 Hemorrhoids,1st degree bulge into the lumen 2nd degree prolapse with bowel movement but reduce spontaneously 3rd degree prolapse spontaneously and require manual reduction 4th degree permanently prolapsed hemorrhoids that cannot be reduced,4th Degree Hemorrhoids,HemorrhoidsTreatment Principles,Thor

26、ough physical exam to determine severity and rule out other pathology Refer for surgical evaluation if white or discolored, firm or fixed Determine if the problem is internal, external or both Assess the symptom complex,Treatment,Topical agents: Proctofoam, Anusol HC Analpram, Proctosol cream Conser

27、vative therapy Bulk agents i.e. high fiber Fruits, vegetables, oat bran, psyllium Increase water intake Avoid caffeinated beverages Avoid prolonged sitting on the commode Warm tub soaks,TreatmentOffice and Minor Procedures,Rubber band ligation Performed in the office Indicated for Grade 1 and 2 inte

28、rnal hemorrhoids Band is applied through an anoscope at the top of an internal hemorrhoid Severe perianal sepsis Classic Triad Delayed anal pain Urinary retention Fever,TreatmentOffice and Minor Procedures,Infrared Photocoagulation Indicated in 1st degree hemorrhoids Causes photocoagulation of small

29、 vessels Performed in office or “Hemorrhoid Relief Center” Minimal pain,Closed HemorrhoidectomyIndication,Hemorrhoids are severely prolapsed and require manual replacement Patients fail to improve after multiple applications of non-operative treatment Hemorrhoids are complicated by associated pathol

30、ogy such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tags,Closed HemorrhoidectomyGeneral Principle,Most can be performed with local and IV Sedation Prone/Kraske position is the best Infuse the area with local anesthetic with epinephrine for hemostasis Fleets e

31、nema 1-2 hours prior No antibiotic prophylaxis is necessary,Closed Hemorrhoidectomy,Closed Hemorrhoidectomy,Closed HemorrhoidectomyPost op Result,PPH Stapling Procedure for Hemorrhoids,Not for every hemorrhoid Ideal for Grade 2 and 3 with minimal external component Prevents prolapse and thus less tr

32、auma to hemorrhoid with bowel movement,PPH Stapling Procedure for Hemorrhoids,PPH Stapling Procedure for Hemorrhoids,Benefits Less pain as compared to traditional closed hemorrhoidectomy Less blood loss during the procedure Less chance of anal stenosis,PPH Stapling Procedure for Hemorrhoids,Risks If

33、 staple placed too low severe chronic pain and incontinence If staple line placed too high failure to relieve symptoms of hemorrhoids Hemorrhoids are not removed so they may continue to bleed Perianal sepsis Rectovaginal fistula,Perianal Condyloma,Can sometimes be difficult to distinguish from hemor

34、rhoids Cauliflower type appearance History of HIV, History of abnormal pap smear Homosexual males usually but can be seen in the heterosexual population Caused by HPV virus Increased risk of anal cancer in the immunocompromised patient,Treatment - Topicals,Aldara (Imiquinod) 50% initial response Top

35、ical 5-FU 90% initial response Condylox (podofilox) Each have high local toxicity Practice Parameters for Anal SquamousNeoplasms www.fascrs.org,Treatment,Photodynamic therapy Wide Local Excision Targeted destruction with cautery and/or Infrared coagulation Observation of AIN I/II with removal of visualized lesions Excision of AIN III,Anal Squamous AIN,High recurrence rate with all techniques Close follow up to detect progression to invasive carcinoma Anal pap smear vs high resolution anoscopy Optomize underlying conditions,Questions?,?,