HEMORRHOIDS AND

ANAL FISSURE
https://www.youtube.com/watch?v=NGNM03a-rlo
 Outline
• ANATOMY OF ANAL CANAL
• ANO-RECTAL PATHOLOGIES
• HEMORRHOIDS DEFINITION
• INTERNAL HEMORRHOIDS VRS EXTERNAL HEMORRHOIDS
• CLINICAL PRESENTATION, STAGES(DEGREES) AND
COMPLICATIONS
• DIAGNOSTIC WORK-UP
• TREATMENT
• ANAL FISSURE
 ANAL CANAL
• Terminal end of the gut; 3.8cm. Begins 2cm below the tip of the
coccyx.
• Junction of colonic epithelium and stratified squamous epithelium
(anoderm); only the part below Hilton's line is keratinized and
continuous with skin and its appendages- hair sweat glands,
• 3 parts – above pectinate line/dentate, Intermediate, and below Hilton’s
White line
• Anal columns of Morgagni, anal sinuses
• Sphincters- internal (longitudinal,circular), external (subcutaneous ,
superficial and deep)
• Blood supply; dual ; superior rectal artery/middle and inferior rectal
arteries.
Anorectal pathologies
• Malformations(imperforate anus)/Neurologic/sphincter disorders
• Rectal prolapse
• Rectal varices in Portal hypertension
• Rectal incontinence/anal incontinence
• Tumors within the rectum/ anal canal
• Piles/Hemorrhoids
• Anal fissure /fissure in-ano
• Fistula in ano
• Crohn’s disease
• Infections; pyogenic, LGV(Chlamydia trachomatis),
 hemorrhoids
• Prevalence; 5%. Peak 45-65years. Rare before 20 years. (Not to be
confused with rectal varices of portal hypertension).
• Risk factors; anorectal deformity/ascites/gravid uterus/uterine
neoplasm/paraplegia/multiple sclerosis/spinal tumors: secondary
HEMORRHOIDS
• Types; internal –above the dentate line, lined by mucus membrane.
• External; below Dentate line, lined by skin, sensory cutaneous
innervation.
• Internal/external = progression of the internal hemorrhoids below the
dentate line.
Internal hemorrhoids
• Clinical features; degrees. 1st/2nd/3rd/4th. Painless-bright red-
ANAL FISSURE/FISSURE IN-ANO
• Types and etiology
• Clinical features
• Diagnosis
• Treatment –conservative
-operative
Anal fissure vrs Hemorrhoids
Anal fissure; clinical features
• Painful, Linear
• Sudden onset. May last for hours after stool.
• Bleeding is not profuse
• Equal in both sexes
• Younger and middle age;
Anal fissure; predisposing factors
• Hard stools, Low fibre diet,
• Previous anal surgery,
• Childbirth
• HIV, syphilis,
• Anal intercourse,
• Crohn’s dx,
• Anal cancer
• High resting pressure in anal canal
Anal fissure; Diagnosis and treatment
• Diagnosis is clinical: history and exam. No labs or imaging required
except to rule out other pathology.
• Rectal exam in acute fissure is to be avoided on account of pain.
Treatment;
• Firstline- conservative (stool softeners, sitz baths, analgesic creams,
Nifedipine ointment. oral analgesia)- most patient recover.
• Next: botox injection to sphincter muscle; Protein Rich Plasma to
fissure (PRP)- heals in 6 weeks
• Surgical intervention; laser fissure excision, lateral internal
sphincterotomy.