Workup in anorectal conditions

Dr Sumedh Wasnik
MS,MBA,PGDCR,DPN,FDFM,FIID,FARSC,Ph.D.

Professor,PG & Ph.D.guide and Head,

Dept of general surgery
PMT Ayu College,Shevgaon
Dist- Ahmednagar
Maharashtra state

Consultant gen.surgeon and proctologist @

Sushrut Surgical Hospital
Siddhivinayak Hospital
 Outcomes
 Introduction

 Surgical anatomy

 List of diseases

 Assessment

 Types of investigations

 Routine investigations

 Special investigations

 Applied aspects

 Take home message

 Introduction
 INVESTIGATIONS-

 Measures to help in diagnosis/treatment

 Supportive tools
 Documentation
 medicolegal purpose
 Increase demand by patients/relatives
 Should aim to answer specific clinical
question where there is doubt as to
diagnose.
 INVESTIGATIONS

 Appropriate
 Rational
 Cost effective
 Feasible
 High value
 Types

1.Laboratorical – hematology, serology

2.Radiological –
Non invasive- X-ray,USG,CT scan, MRI
Invasive- scopy
3.Special- isotope scanning, arteriography

1.Anatomical [structural]- xray,usg

2.Physiological[functional]-manometry
Rectum - Relations
List of anorectal diseases
1.Congenital-
2.Acquired-
• Trauma/injury
• Infective
• Inflammatory
• Benign
• Malignancies
• Miscellaneous

1.Primary-
2.Secondary-

1.Anal
2.Perianal
 Congenital anorectal conditions-
 Since birth
 Developmental deformities of lower end of alimentary canal
 Incidence- minor-1 in 500,major-1 in 5000

 Types-
 1.high-
Agenesis with or without fistula
Atresia
Cloaca
 2.low-
 Covered anus
 Ectopic anus-perineal,vulval,vaginal
 Stenosed anus
 Anorectal membrane

 3.sacrococcygeal teratoma
 4.post anal dermoid
 5.polyp
 Trauma/injury
 Sudden or insidious
 Incidence-1% civilians,5%military
 Blunt or penetrating
 Often associated with injuries to adjacent
structures
 Pelvic fracture
 Multiorgan/multisystemic
 Iatrogenic
 Unsafe sex
 Sexual assaults
 Infectious/inflammatory
conditions
 Proctocolitis
 Proctitis
 Perianal boil
 Anorectal abscess
 Perianal abscess
 Anal fissure
 Anal rectal fistula
 Rectal ulcer
Benign conditions

 Hemorrhoids/piles
 Prolapse-partial/complete
 Proctalgia
 polyp
 Condyloma
 Warts
 Sebaceous cyst
 Lipoma
 Mole
 Leiomyoma
 Malignancies
 1.Rectal – 1% in 1 million
 Most common –adenocarcinoma
 Less common-
lymhoma,leiomyosarcoma,carcinoid
tumour,GIST,melanoma

 2.Anal- 1% of GIT
 Most common-squamous cell carcinoma
 Less common- adenocarcinoma,basal cell
carcinoma,melanoma,GIST
 Miscellaneous conditions

 Constipation- acute,chronic,habitual
 Exaggerated gastro-colic reflex
 Proctalgia fugax
 Pruritus ani
 Fecal incontinence
 Stricture
 Pilonidal sinus
 Excessive perineal descent
 Pelvic floor dyssynergia
 Symptomatology

 Constipation
 Pain
 Bleeding P/R
 Protrusion/mass
 Fever/temp
 Lower abdominal pain
 Loose motions
 Tenesmus
 Discharge
 Itching/pruritus
 Anorexia
 Loss of weight
 Weakness
 Assessment

1.History- patient’s details,

present,past,personal,family,drug,allergy

2.Examination-general,systemic,local

3.Diagnosis-differential,provisional,confirm

4.Investigations-routine,special

5.Management-conservative,parasurgical,surgical
Congenital malformation screening

 History- especially family

 X ray

 USG

 CT scan

 MRI
Trauma/injury screening

 History
 Clinical exam
 Hematology
 USG
 CT Scan- plain/contrast
 Laparoscopy
 Explorative laparotomy
 INFECTION SCREENING
 History
 Clinical exam
 P/R & Proctoscopy
 CBC
 BSL
 USG
 Endoscopy
 CT,MRI- SOS
 Anemia screening

 History
 Clinical exam
 P/R & Proctoscopy
 CBC
 CT,BT,PT,Blood group
 RFT,LFT
 USG abd.pelvis
 Endoscopy
 CT scan,MRI
 Cancer screening
 History
 Examination
 P/R & Proctoscopy
 USG
 Endoscopy
 CT scan
 MRI
 Radio scan
 P/R [DRE]
 Evaluation
🞑 Rectal masses
🞑 Prostatic disorders (tumours and BPH)
🞑 Haemorrhoids
 Gynecological palpations of internal organs
 Estimation of the tonicity of the anal sphincter
🞑 fecal incontinence
🞑 neurologic diseases, including traumatic spinal cord
injuries
 Examination of stool
 Prior to a colonoscopy or proctoscopy
 In newborns to exclude imperforate anus
Digital Rectal Examination
 Ano-rectal sling, ischiorectal fossa, ischial spines

 Males
🞑 Posterior surface of prostate
🞑 Seminal vesicles
🞑 Vas deferens

 Females
🞑 Perineal body
🞑 Cervix
Anorectal malformation
Physiological tests of asses pelvic floor
 Special tests

 Barium studies
 Rectal evacuation studies
 Pudendal nerve conduction studies
 Radio scan – T99
 Tumor markers
 Genetic testing
 Capsule endoscopy
 Biopsy
 Check list
 History
 Examination
 P/R & Proctoscopy
 Routine investigations
 Special investigations
 Opinion
 Follow ups
 Take home message

• Appropriate investigations are compulsory for

diagnostic and therapeutic purpose.
• Anatomical[structural]&physiological[functional]
• Supportive tools.
• Don’t depend 100%, judge and corelate clinically
• Medicolegal value.
• If the patient is not willing for investigations, just write
down what you advised on OPD/IPD/OT paper.
• Proper history, detail clinical exam have edge over
investigations.
• Keep updating yourself.
Thank you