MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS

ESTABLISHMENT OF EDUCATION "VITEBSK STATE ORDER

FRIENDSHIP OF PEOPLES MEDICAL”

REFERATH

Disease of Rectum (Hemmorrhoids , Anal fissures , Acute and Chronic

Paraproctitis

TALAL
MOHAMMAD
Group No 52

Teacher in charge
М.И.КУГАЕВ

Vitebsk 2021
Anal fissure

An anal fissure is a painful linear tear or crack in the distal anal canal,
which, in the short term, usually involves only the epithelium and, in the
long term, involves the full thickness of the anal mucosa.
Anal fissures develop with equal frequency in both sexes; they tend to
occur in younger and middle-aged persons.
Anatomy

A thorough knowledge of the anatomy of the anal canal is vital for

effective surgical treatment of an anal fissure.
These two terms are often used interchangeably, even though they do
not mean the same thing.
The surgical anal canal is approximately 4 cm long and extends from
the anal verge or intersphincteric groove distally to the anorectal ring,
proximally.
The anatomic anal canal is only approximately 2 cm long and extends
from the anal verge distally to the dentate line proximally
Pathophysiology and Etiology

The exact etiology of anal fissures is unknown, but the initiating factor
is thought to be trauma from the passage of a particularly hard or
painful bowel movement.
Low-fiber diets (eg, those lacking in raw fruits and vegetables) are
associated with the development of anal fissures.
No occupations are associated with a higher risk for the development of
anal fissures.
Prior anal surgery is a predisposing factor because scarring from the
surgery may cause either stenosis or tethering of the anal canal, which
makes it more susceptible to trauma from hard stool.

Initial minor tears in the anal mucosa due to a hard bowel movement
probably occur often.
In most people, these heal rapidly without long-term sequelae.
In patients with underlying abnormalities of the internal sphincter,
however, these injuries progress to acute and chronic anal fissures.
Studies of the internal anal sphincter and of anal canal physiology have
been performed with varied results, but at least one abnormality is
likely present in the internal anal sphincter of many anal fissure
patients.
The most commonly observed abnormalities are hypertonicity and
hypertrophy of the internal anal sphincter, leading to elevated anal
canal and sphincter resting pressures.
The internal sphincter maintains the resting pressure of the anal canal;
anal-rectal manometry can be used to measure this pressure.
Most patients with anal fissures have an elevated resting pressure,
which returns to normal levels after surgical sphincterotomy.
The posterior anal commissure is the most poorly perfused part of the
anal canal.

In patients with hypertrophied internal anal sphincters, this delicate

blood supply is further compromised, thus rendering the posterior
midline of the anal canal relatively ischemic.
This relative ischemia is thought to account for why many fissures do
not heal spontaneously and may last for several months.
Pain accompanies each bowel movement as this raw area is stretched
and the injured mucosa is abraded by the stool.

The internal sphincter also begins to spasm when a bowel movement is

passed. This spasm has two effects: First, it is painful in itself, and
second, it further reduces the blood flow to the posterior midline and
the anal fissure, contributing to the poor healing rate.
Prognosis

Approximately 1-6% of patients have a recurrence of their anal fissure

after sphincterotomy.
The recurrence rate is higher after a sphincter stretch. If a patient
develops a recurrence after a sphincterotomy, it could be from
recurrent disease or from an improperly or incompletely performed
initial sphincterotomy.

In the event of a recurrence, medical management should be attempted

again, but if no relief is obtained, the surgeon must evaluate whether
the original sphincterotomy was adequate.
Evaluation can be performed by means of palpation during
examination under anesthesia or by means of endoanal
ultrasonography.
If the sphincterotomy was incomplete, it can be completed on the initial
side or redone on the opposite side.
If the first sphincterotomy was complete, a second sphincterotomy can
be completed on the opposite side.
History

Typically, the symptoms of an anal fissure are relatively specific, and

the diagnosis can often be made on the basis of the history alone.
However, like other common benign anal pathologic conditions, anal
fissure is sometimes misdiagnosed or mistaken for another condition of
this type.

Typically, the patient reports severe pain during a bowel movement,

with the pain lasting several minutes to hours afterward.
The pain recurs with every bowel movement, and the patient commonly
becomes afraid or unwilling to have a bowel movement, leading to a
cycle of worsening constipation, harder stools, and more anal pain.
Approximately 70% of patients note bright-red blood on the toilet paper
or stool.

Occasionally, a few drops may fall in the toilet bowl, but significant
bleeding does not usually occur with an anal fissure.

Physical Examination

Initially, the fissure is just a tear in the anal mucosa and is defined as an
acute anal fissure. If the fissure persists over time, it progresses to a
chronic fissure that can be distinguished by its classic features.
The fibers of the internal anal sphincter are visible in the base of the
chronic fissure, and often, an enlarged anal skin tag is present distal to
the fissure and hypertrophied anal papillae are present in the anal canal
proximal to the fissure. (See the images below.)

Laboratory Studies

1. Erythrocyte sedimentation rate (ESR)

2. Stool and viral cultures
 3. HIV testing
4. Biopsy of the lesion or fissure

Diagnostic Procedures

The diagnosis of anal fissure can usually be made on the basis of

findings from a gentle perianal examination with inspection of the anal
mucosa, in conjunction with a good history.
In this case, no diagnostic procedures are required.
A digital rectal examination (DRE) is painful and often can be deferred.

Occasionally, the fissure is not easily visualized, and anoscopy is

required to see it.
However, anoscopy is not well tolerated by a patient with an acute anal
fissure, and the procedure can often be deferred, with the patient
treated solely on the basis of symptoms.
Occasionally, a topical application of 1-2% lidocaine facilitates the
examination.

Treatment

Failure of medical therapy to resolve the acute fissure is an indication

for surgical intervention.
The presence of a symptomatic chronic fissure is also an indication for
surgery because few of these heal spontaneously.

The main contraindication to surgery for an anal fissure is impaired

fecal continence, a state that could be exacerbated by surgery.
This contraindication mostly applies to patients with minor incontinence
(occasional seeping).
Patients with gross fecal incontinence (solid material) rarely develop
fissures; however, those with irritable bowel syndrome and
incontinence to liquid stool can develop fissures if they become
constipated. These patients are at the most risk for surgical treatment
of an anal fissure, because their typical bowel pattern is loose and
harder to control.

Medical Therapy
First-line medical therapy consists of therapy with stool-bulking agents,
such as fiber supplementation and stool softeners.
Laxatives are used as needed to maintain regular bowel movements.
Mineral oil may be added to facilitate passage of stool without as much
stretching or abrasion of the anal mucosa, but it is not recommended
for indefinite use.
Sitz baths after bowel movements and as needed provide significant
symptomatic relief because they relieve some of the painful internal
sphincter muscle spasm.
Recurrence rates are in the range of 30-70% if the high-fiber diet is
abandoned after the fissure is healed. This range can be reduced to 15-
20% if patients remain on a high-fiber diet.

Second-line medical therapy consists of intra-anal application of 0.4%

nitroglycerin (NTG; also called glycerol trinitrate) ointment directly to
the internal sphincterNitroglycerin rectal ointment is approved by the
US Food and Drug Administration (FDA) for moderate-to-severe pain
associated with anal fissures and may be considered when conservative
therapies have failed.

Hemmoroids
Hemorrhoids also called piles, are swollen veins in your anus and lower
rectum, similar to varicose veins. Hemorrhoids can develop inside the
rectum (internal hemorrhoids) or under the skin around the anus
(external hemorrhoids).

Nearly three out of four adults will have hemorrhoids from time to time.
Hemorrhoids have a number of causes, but often the cause is unknown.

Fortunately, effective options are available to treat hemorrhoids. Many

people get relief with home treatments and lifestyle changes.
Symptoms
Signs and symptoms of hemorrhoids usually depend on the type of
hemorrhoid.

External hemorrhoids

These are under the skin around your anus. Signs and symptoms might
include:

 Itching or irritation in your anal region

  Pain or discomfort
 Swelling around your anus
 Bleeding
Internal hemorrhoids

Internal hemorrhoids lie inside the rectum. You usually can't see or feel
them, and they rarely cause discomfort. But straining or irritation when
passing stool can cause:

 Painless bleeding during bowel movements. You might notice

small amounts of bright red blood on your toilet tissue or in
the toilet.
 A hemorrhoid to push through the anal opening (prolapsed or
protruding hemorrhoid), resulting in pain and irritation.
Thrombosed hemorrhoids

If blood pools in an external hemorrhoid and forms a clot (thrombus), it

can result in:

 Severe pain
 Swelling
 Inflammation
 A hard lump near your anus
When to see a doctor

If you have bleeding during bowel movements or you have hemorrhoids

that don't improve after a week of home care, talk to your doctor.
Don't assume rectal bleeding is due to hemorrhoids, especially if you
have changes in bowel habits or if your stools change in color or
consistency. Rectal bleeding can occur with other diseases, including
colorectal cancer and anal cancer.

Seek emergency care if you have large amounts of rectal bleeding,

lightheadedness, dizziness or faintness.

Causes

The veins around your anus tend to stretch under pressure and may
bulge or swell. Hemorrhoids can develop from increased pressure in the
lower rectum due to:

 Straining during bowel movements

 Sitting for long periods of time on the toilet
 Having chronic diarrhea or constipation
 Being obese
 Being pregnant
 Having anal intercourse
 Eating a low-fiber diet
 Regular heavy lifting
Risk factors

As you age, your risk of hemorrhoids increases. That's because the

tissues that support the veins in your rectum and anus can weaken and
stretch. This can also happen when you're pregnant, because the baby's
weight puts pressure on the anal region.
Complications

Complications of hemorrhoids are rare but include:

 Anemia. Rarely, chronic blood loss from hemorrhoids may

cause anemia, in which you don't have enough healthy red
blood cells to carry oxygen to your cells.
 Strangulated hemorrhoid. If the blood supply to an internal
hemorrhoid is cut off, the hemorrhoid may be "strangulated,"
which can cause extreme pain.
 Blood clot. Occasionally, a clot can form in a hemorrhoid
(thrombosed hemorrhoid). Although not dangerous, it can be
extremely painful and sometimes needs to be lanced and
drained.
Prevention

The best way to prevent hemorrhoids is to keep your stools soft, so they
pass easily. To prevent hemorrhoids and reduce symptoms of
hemorrhoids, follow these tips:

 Eat high-fiber foods. Eat more fruits, vegetables and whole

grains. Doing so softens the stool and increases its bulk, which
will help you avoid the straining that can cause hemorrhoids.
Add fiber to your diet slowly to avoid problems with gas.
 Drink plenty of fluids. Drink six to eight glasses of water and
other liquids (not alcohol) each day to help keep stools soft.
 Consider fiber supplements. Most people don't get enough of
the recommended amount of fiber — 20 to 30 grams a day —
in their diet. Studies have shown that over-the-counter fiber
supplements, such as psyllium (Metamucil) or methylcellulose
 (Citrucel), improve overall symptoms and bleeding from
hemorrhoids.
If you use fiber supplements, be sure to drink at least eight
glasses of water or other fluids every day. Otherwise, the
supplements can cause or worsen constipation.

 Don't strain. Straining and holding your breath when trying

to pass a stool creates greater pressure in the veins in the
lower rectum.
 Go as soon as you feel the urge. If you wait to pass a bowel
movement and the urge goes away, your stool could dry out
and be harder to pass.
 Exercise. Stay active to help prevent constipation and to
reduce pressure on veins, which can occur with long periods of
standing or sitting. Exercise can also help you lose excess
weight that might be contributing to your hemorrhoids.
 Avoid long periods of sitting. Sitting too long, particularly on
the toilet, can increase the pressure on the veins in the anus.

Diagnosis

Your doctor might be able to see external hemorrhoids. Diagnosing

internal hemorrhoids might include examination of your anal canal and
rectum.

 Digital examination. Your doctor inserts a gloved, lubricated

finger into your rectum. He or she feels for anything unusual,
such as growths.
  Visual inspection. Because internal hemorrhoids are often too
soft to be felt during a rectal exam, your doctor might
examine the lower portion of your colon and rectum with an
anoscope, proctoscope or sigmoidoscope.
Your doctor might want to examine your entire colon using colonoscopy
if:

 Your signs and symptoms suggest you might have another

digestive system disease
 You have risk factors for colorectal cancer
 You are middle-aged and haven't had a recent colonoscopy
Treatment

Home remedies

You can often relieve the mild pain, swelling and inflammation of
hemorrhoids with home treatments.

 Eat high-fiber foods. Eat more fruits, vegetables and whole

grains. Doing so softens the stool and increases its bulk, which
will help you avoid the straining that can worsen symptoms
from existing hemorrhoids. Add fiber to your diet slowly to
avoid problems with gas.
 Use topical treatments. Apply an over-the-counter
hemorrhoid cream or suppository containing hydrocortisone,
or use pads containing witch hazel or a numbing agent.
 Soak regularly in a warm bath or sitz bath. Soak your anal
area in plain warm water for 10 to 15 minutes two to three
times a day. A sitz bath fits over the toilet.
  Take oral pain relievers. You can use acetaminophen
(Tylenol, others), aspirin or ibuprofen (Advil, Motrin IB, others)
temporarily to help relieve your discomfort.
With these treatments, hemorrhoid symptoms often go away within a
week. See your doctor in a week if you don't get relief, or sooner if you
have severe pain or bleeding.

Medications

If your hemorrhoids produce only mild discomfort, your doctor might

suggest over-the-counter creams, ointments, suppositories or pads.
These products contain ingredients such as witch hazel, or
hydrocortisone and lidocaine, which can temporarily relieve pain and
itching.

Don't use an over-the-counter steroid cream for more than a week

unless directed by your doctor because it can thin your skin.

External hemorrhoid thrombectomy

If a painful blood clot (thrombosis) has formed within an external

hemorrhoid, your doctor can remove the hemorrhoid, which can
provide prompt relief. This procedure, done under local anesthesia, is
most effective if done within 72 hours of developing a clot.

Minimally invasive procedures

For persistent bleeding or painful hemorrhoids, your doctor might

recommend one of the other minimally invasive procedures available.
These treatments can be done in your doctor's office or other outpatient
setting and don't usually require anesthesia.
 Rubber band ligation. Your doctor places one or two tiny
rubber bands around the base of an internal hemorrhoid to
cut off its circulation. The hemorrhoid withers and falls off
within a week.
Hemorrhoid banding can be uncomfortable and cause
bleeding, which might begin two to four days after the
procedure but is rarely severe. Occasionally, more-serious
complications can occur.

 Injection (sclerotherapy). Your doctor injects a chemical

solution into the hemorrhoid tissue to shrink it. While the
 injection causes little or no pain, it might be less effective than
rubber band ligation.
 Coagulation (infrared, laser or bipolar). Coagulation
techniques use laser or infrared light or heat. They cause
small, bleeding internal hemorrhoids to harden and shrivel.
Coagulation has few side effects and usually causes little
discomfort.
Surgical procedures

Only a small percentage of people with hemorrhoids require surgery.

However, if other procedures haven't been successful or you have large
hemorrhoids, your doctor might recommend one of the following:

 Hemorrhoid removal (hemorrhoidectomy). Choosing one of

various techniques, your surgeon removes excessive tissue
that causes bleeding. The surgery can be done with local
anesthesia combined with sedation, spinal anesthesia or
general anesthesia.
Hemorrhoidectomy is the most effective and complete way to
treat severe or recurring hemorrhoids. Complications can
include temporary difficulty emptying your bladder, which can
result in urinary tract infections. This complication occurs
mainly after spinal anesthesia.
Most people have some pain after the procedure, which
medications can relieve. Soaking in a warm bath also might
help.
 Hemorrhoid stapling. This procedure, called stapled
hemorrhoidopexy, blocks blood flow to hemorrhoidal tissue. It
is typically used only for internal hemorrhoids.
 Stapling generally involves less pain than hemorrhoidectomy
and allows for earlier return to regular activities. Compared
with hemorrhoidectomy, however, stapling has been
associated with a greater risk of recurrence and rectal
prolapse, in which part of the rectum protrudes from the
anus.
Complications can also include bleeding, urinary retention and
pain, as well as, rarely, a life-threatening blood infection
(sepsis). Talk with your doctor about the best option for you.

Paraproctitis
Paraproctitis is a purulent inflammation of the
cellular tissues surrounding the rectum. The most frequent cause is
penetration of bacterial flora from the rectum into the surrounding
cellular tissues, which may occur through an anal fissure. The
inflammation is sometimes limited to the formation of an anorectal
abscess, and in some cases it spreads for a considerable distance and
may be complicated by sepsis.
The symptoms are acute pain in the rectal region, tenderness
during defecation, elevated body temperature, and the appearance of
an infiltrate in the anal region or on the buttocks. An unlanced abscess
may burst and a fistula form. The disease becomes chronic after
recurrences. Treatment includes administration of antibiotics and anti-
inflammatory agents and, in the suppurative stage, surgical lancing of
any anorectal abscess.
 Reference List
https://www.google.by/search?
hl=en&sxsrf=ALeKk021rsqrtI38L_NVOtotzNSfd9-ZwA
%3A1614620820069&source=hp&ei=lCg9YMTaAcG5kwWO9aegCw&ifl
sig=AINFCbYAAAAAYD02pLJePWfgDDhS4HlwAWekGakPY66-
&q=paraproctitis&oq=pa&gs_lcp=Cgdnd3Mtd2l6EAEYADIECCMQJzIECC
MQJzIECCMQJzIECAAQQzIECAAQQzICCAAyCAguEMcBEKMCMgIIADICC
AAyCAguEMcBEKMCOgcIIxDqAhAnOgcILhDqAhAnUIMHWLMIYIYdaAB
wAHgBgAGxDIgBwx2SAQc2LTEuMS4xmAEAoAEBqgEHZ3dzLXdperABCg
&sclient=gws-wiz
https://en.wikipedia.org/wiki/Paraproctitis#:~:text=Paraproctitis%20is
%20a%20purulent%20inflammation,occur%20through%20an%20anal
%20fissure.
https://www.mayoclinic.org/diseases-
conditions/hemorrhoids/symptoms-causes/syc-20360268