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ANUS and RECTUM

Gerardo R. Wenceslao, MD, FPCS,FPSGS

RECTUM
Anus and Rectum
 Anorectal landmarks

 Rectum

 12-15 cm
 Valves of Houston
3 submucosal folds
 Surgical anal canal
 2-4 cm
 Anorectal junction to anal verge
 Anorectal landmarks

 Dentate line

 Transition point between columnar rectal mucosa and squamous

anoderm
 Columns of Morgagni
 Longitudinal mucosal folds which anal crypts empty
 Presacral fascia

 Separates the rectum from presacral venous plexus and nerves

 Waldeyer's fascia

 Retrosacral fascia that extends downward and forward and attaches

to fascia proper at the ano rectal junction
 Pecten

 Below is lined by Stratified squamous epithelium

 It is covered by transitional epithelium

 At this line the external sphincter replaces the

internal

 Skin below this line is supplied by inferior

hemorrhoidal nerve ( pain fibers) mucosa proximal
is supplied by sympathetic fibers
 Pecten
 Internal hemorrhoids occurs above this
line and external hemorrhoids below
 Marks the dividing line between superior
and inferior hemorrhoidal vessels
 85% of proctologic conditions occur in
this area
Anal Sphincters
Sphincters

 Internal sphincter
 thickened portion of the lower circular
smooth muscle of the bowel
 Encloses the upper 2/3 of the anal canal
 External sphincter
Anal Sphincter
Pelvic Floor
Blood supply of the Rectum and Anus
 Defecation

 Distention of the rectum

 Relaxation of the internal anal sphincter ( rectoanal inhibitory
reflex)
 Allows contents to make contact with anal canal
Sampling reflex- allows sensory epithelium to distinguish solid
stool from liquid and gas
 Ifdefecation does not occur the rectum relaxes and the urge to
defecate passes-accommodation response
 Valsalva maneuver
 Increased rectal contraction
 Relaxation of the puborectalis muscle
 Opening of the anal canal
 Continence

 Adequate rectal wall compliance

 Appropriate neurogenic control of the pelvic floor and sphincter mechanism
 Functional internal and external sphincter muscles
 Internal sphincter
 Provides much of the resting and involuntary sphincter tone
 External sphincter
 Provides most of the voluntary sphincter tone -squeeze pressure
 Puborectalis muscle
 At rest provides a sling around the distal rectum-forming an acute angle
 With defecation the angle straightens-allowing downward force applied
along the rectum and anal canal
 Hemorrhoidal cushions
Anoscope
Proctoscopy
Endorectal and endoanal
ultrasound
Manometry
 Manometry

 Resting pressure ( 40-80 mmHg)

 Reflects the function of the internal sphincter
 Squeeze pressure ( 40-80 mmHg above the resting pressure)
 Maximum voluntary contraction minus resting pressure
 Reflects function of the external sphincter
 High pressure zones
 Estimates the length of the anal canal
 Rectoanal inhibitory reflex
 Detected by inflating the balloon in the distal rectum
Hemorrhoids
 Benign Anorectal Disease
 Hemorrhoids

 Cushions of complex submucosal tissues

containing arterioles, venules and smooth muscle
fibers
 Function as part of the continence mechanism by
protecting the sphincter during defecation and
permits complete closure of the anus at rest
 Excessive straining, increased abdominal pressure
and hard stools- increases venous engorgement of
hemorrhoidal plexus and prolapse of the
hemorrhoidal tissues
 Hemorrhoids
3 regions of Fibrovascular
cushions (PILES) in Anal canal
Left lateral, Right posterior and
Right anterior
when one of these cushions
becomes abnormally large and
produces symptoms it is called
Haemorrhoid
Subcategorized based on their
location relative to dentate line.
EXTERNAL
HEMORRHOID( below the
dentate line) INTERNAL
HAEMORRHOID (above the
dentate line)
 Classification

 Combined internal and external hemorrhoids

 Post-partum hemorrhoids

 Rectal varices

 Best treated by lowering portal venous

pressure

 Surgical hemorrhoidectomy must be avoided

Symptoms
 Bleeding, mucous discharge, prolapse and
pruritus
 Internal hemorrhoids seldom cause pain unless
acutely prolapsed and incarcerated
 Treatment

 Hemorrhoids are normal part of anorectal anatomy,

treatment is indicated only if they are symptomatic
 Medical treatment
 Bleeding from 1st and 2nd degree hemorrhoids often
improves with dietary fiber, stool softeners, increased
fluid intake and avoidance of straining
 Rubber band ligation
 Persistent
bleeding from 1st, 2nd and 3rd degree
hemorrhoids
 Treatment

 Rubber band ligation

 In general 1 or 2 quadrants are banded per visit
 Complications

 Bleeding

 Severe pain
 If rubber band is placed at or distal to the dentate line
 Urinary retention
 Occurs in 1% of patients
 If ligation included a portion of the internal sphincter
 Rubber band ligation

 Complications

 Necrotizing infection
 Uncommon but a life threatening complication
 Severe pain , fever and urinary retention
 Treatment

 Debridement

 Drainage of associated abcess

 Broad spectrum antibiotics
 Treatment

 Infrared photocoagulation
 Small 1st and 2nd degree hemorrhoids
 Not effective against large hemorrhoids or those with
significant prolapse
 All 3 quadrants maybe treated during the same visit
 Sclerotherapy

 Office treatment for 1st, 2nd and 3rd degree

 Sclerosingagents ( phenol in olive oil, sodium
morrhuate) are injected to the submucosa
Treatment
 Operativehemorrhoidectomy
 Decrease blood flow to the hemorrhoidal tissues
and excising redundant anoderm and mucosa
 Usually done for 3rd and 4th degree
hemorrhoids
Ferguson Hemorrhoidectomy
 Treatment

 Operative hemorrhoidectomy
 Closed submucosal hemorrhoidectomy
 Parksor Ferguson- resection of hemorrhoidal
tissues and closure of the wound by
absorbable sutures
 Allthe 3 hemorrhoidal cushions can be
removed but must avoid resecting large area
of perianal skin to prevent perianal stenosis
 Operative hemorrhoidectomy
 Open hemorrhoidectomy
 Milligan and Morgan
 Wounds are left open and allowed to heal by
secondary intention
Whitehead Hemorrhoidectomy
 Open hemorrhoidectomy

 Whiteheads hemorroidectomy

 Circumferential excision of hemorrhoidal cushions

proximal to the dentate line

 Rectal mucosa is advanced and sutured to the dentate

line

 No longer popularly used because of risk of ectropion

( whitehead's deformity)
Whiteheads deformity
PPH
 Operative hemorrhoidectomy

 Procedure for Prolapse and Hemorrhoids ( PPH)

 No excision of hemorrhoidal tissues

 Removes a short circumferential segment of rectal mucosa

proximal to the dentate line using a circular stapler

 Effectively ligates venules feeding the hemorrhoidal plexus

 Fixes redundant mucosa proximal to the dentate line

 Complications of hemorrhoidectomy

 Pain

 Urinary retention

 Fecal impaction

 Bleeding

 Immediate post- op period

 7-10 days after surgery

Long
term sequelae of
hemorrhoidectomy
Incontinence
Anal stenosis
Ectropion
Thrombosed external
hemorrhoids
 Treatment

 Excision of thrombosed external hemorrhoids

 Intense pain and palpable mass during first 24- 72

hours

 After 72 hours the clot begins to resorb, pain resolves

spontaneously

 Excision is unnecessary, needs only hot stiz bath and

analgesics
Anal tags
ANAL FISSURE
 ANAL FISSURE

 Tear in the anoderm distal to the dentate line

 Tearis due to the passage of hard stools or prolonged
diarrhea
 Tear causes spasm of the internal anal sphincter
 Pain

 Increased tearing
 Decreased blood supply
 Majority occurs at the the posterior midline
 10-15% -anterior midline
 1%- off midline
ANAL FISSURE
 Symptoms
 Pain on defecation that may last several hours
after defecation
 Hematochezia
 Described as blood on the tissue paper
 ANAL FISSURE

 Physical examination
 Fissure in the anoderm
 Acute fissure
 Superficial tear, almost always heals with medical treatment
 Chronic fissure
 Ulceration and heaped -up edges, fibers of the internal sphincter
visible at the base
 With external skin tag or hypertrophied papilla internally
 May require surgery
 Lateral fissure- chron's disease, HIV, tuberculosis or leukemia
Chronic Anal Fissure
 ANAL FISSURE

 Treatment

 Medical- will heal most cases of acute anal fissure.

But effective only in 50- 60% of chronic anal fissures
 Bulks agents, stool softeners warm sitz bath
 2% lidocaine cream
 Nitroglycerineointment- to improve blood supply (
can cause headache)
 Oral and topical calcium channel blockers- less
side effects
 ANAL FISSURES

 Medical treatment
 Arginine

 Topical bethanecol ( muscarinic agonist)

 Botulinum toxin
 Temporary paralysis by preventing acetylcholine
release from presynaptic nerve terminals
 Healing equivalent to other medical therapies
Rectum and Anus
 ANAL FISSURES

 Surgical therapy

 Lateral internal sphincterotomy

 Dividing laterally 30% of the internal sphincter

 Heals 95% of cases

 Gives immediate pain relief

 < 10% recurrence rate

 5-15% rate of incontinence to flatus

Rectum and Anus
 ANORECTAL ABSCESS and FISTULA
 Pathogenesis
 They are cryptoglandular in origin and empty into the anal crypts
 Abscess is an acute stage, a fistula is the chronic stage of the
same disease process
 Most abscess originate in between the internal and external
sphincter ( intersphincteric space)
 Downward extension results in perianal abscess
 Lateral extension through the low external sphincter
-ischiorectal abcess
 Upward extension- supralevator abscess
 Anorectal landmarks

 Dentate line

 Transition point between columnar rectal mucosa and squamous

anoderm
 Columns of Morgagni
 Longitudinal mucosal folds which anal crypts empty
 Presacral fascia

 Separates the rectum from presacral venous plexus and nerves

 Waldeyer's fascia

 Retrosacral fascia that extends downward and forward and attaches

to fascia proper at the ano rectal junction
Anorectal Abscess
Anorectal spaces
Anorectal spaces
Anus and Rectum

 ANORECTAL ABCESS

 Treatment

 Drainage must be done as soon as possible

 Incision and drainage is curative in 50% ; the other 50%

will develop anorectal fistula

 Antibiotics are not required unless there is an extensive

overlying cellulitis or if the patient is
immunocompromised
Perianal abscess
 Perianal Abscess
 Signs and symptoms
 Severe anal pain- the most common complaint
 Walking, straining and coughing aggravates the pain
 Palpable mass on the perianal area or on digital exam
 Swelling and fluctuance are late signs
 Drainage of pus and blood signifies spontaneous rupture and
usually associated with pain relief
 Fever and leukocytosis maybe present
 ANORECTAL ABCESS

 Perianal abscess

 Most can be drained under local anesthesia

 A cruciate skin incision is made over the most

prominent part of the abscess

 " Dog ears" are excised to prevent premature closure

 No packing is required
Perianal abscess
 ANORECTAL ABSCESS
 Ischiorectal abscess
 May present as diffuse swelling of the ischiorectal space
 If both sides are affected may form a " horseshoe" abscess
 Simple ischiorectal abscess
 Direct incision in the overlying skin
 Horseshoe abscess
 May require drainage of deep post anal space
 Incision of the anococcygeal ligament
 Counter drainage on each limb of the ischiorectal space
Horse shoe abscess
Ischiorectal Abscess
 ANORECTAL ABCESS

 Intersphincteric abcess

 Produce little swelling and few perianal signs of infection

 Pain is typically described as being deep and " up inside "

 Pain is usually exacerbated by coughing or sneezing

 DRE may not be possible because of intense pain

 Can be drained through limited posterior internal

sphincterotomy
Intersphincteric abscess
 ANORECTAL ABSCESS

 Supralevator abscess
 May mimic intraabdominal conditions
 DRE- indurated and bulging mass above the anorectal
ring
 Origin of the abscess
 Intra-abdominal disease
 Tx of primary disease and the abscess is drained
via the most direct route
 Upward extension of intersphincteric abscess
 Drained to the rectum
 Upward extension of ischiorectal abcess
 Drained through the ischiorectal space
Supralevator Abscess
Fistula in Ano
Fistula in Ano

 Etiology

 majority are cryptoglandular in origin

 other causes

 tuberculosis

 chron's disease

 trauma

 malignancy
Fistula in Ano

 Diagnosis
 persistent drainage from internal/external opening
 palpable indurated tract
Goodsall's rule
 Intersphincteric
Transphincteric Simple Fistula in Ano
- Low

- High

Suprasphincteric Complex Fistula in Ano

Extrasphincteric

( multiple external openings, anterior fistula in women,

fistulas assets w/ IBD)
Fistula in Ano
Fistulotomy
Fistula in Ano
Seton
Seton
Endorectal advancement flap
Fibrin Glue
Collagen Plug
Collagen Plug
Anal canal and Perianal
tumors
Anal Intraepitheilal Neoplasia
(AIN)
AIN

 Strongly associated with HPV (6,11,16,18)

 Characterize by nuclear and cellular
abnormalities within squamous epithelial cells
limited to the basement membrane
 Involves both the perianal skin and anal canal
AIN

 Risk factors

 Multiple sexual partners

 Anal warts

 Men having sex with men

 Smoking

 Immunosupression
HRA
High Resolution Anoscopy
AIN 1

Nuclear abnormalities confined to the lower 1/3 of

the epithelium

AIN 2

Nuclear abnormalities limited to the lower 2/3

AIN 3

Involves full thickness of the epithelium

AIN

 High grade Squamous Intraepithelial Lesion

( HSIL)- AIN 2 and AIN 3
 Bowen's disease

 Low grade Squamous Intraepithelial Lesion

(LSIL)d( AIN 1)
 Low grade dysplasia
AIN
AIN

 Symptoms

 Pruritus

 Anal discharge

 Pain

 Bleeding

 Tenesmus
AIN

 Treatment

 Repeated ablation

 Laser ablation

 Cryosurgery

 Medical treatment

 Imiquimod

 Topical 5 FU
Squamous Cell Ca
Epidermoid Ca

 Clinical manifestation
 Presents as perianal or intranal mass
 Pain
 Bleeding
 Treatment
 Chemotherapy and radiotherapy
 Nigro protocol
 APR
 Recurrent lesions
Squamous Cell Ca

 Treatment

 Nigro protocol

 3 weeks of radiation

 5fu

 25 mg/ kg for 5 days

 Mitomycin C

 0.5 mg/ kg
Abdominoperineal resection
Buschke-Lowenstein tumor
Anal Melanoma
Rectal prolapse
Rectal prolapse
 Circumferential full thickness protrusion of the
rectum through the anus

 Internal prolapse

 Rectal wall intussuscept but does not protrude

 Mucosal prolapse

 Partial thickness protrusion often associated with

hemorrhoidal disease
Rectal prolapse
 Symptoms

 Tenesmus

 Sensation of tissue protrusion from the anus

 Sensation of incomplete evacuation

 Mucoid discharge

 Incontinence

 Diarrhea

 Obstruction
Moschowitz procedure
The End