Rectal and anal pathology Notes

NOTES NOTES RECTAL & ANAL PATHOLOGY GENERALLY, WHAT IS IT? PATHOLOGY & CAUSES ▪ Diseases affecting rectum and anal region COMPLICATIONS ▪ Discomfort during defecation, itching, pain, bleeding SIGNS & SYMPTOMS DIAGNOSIS ▪ History, physical examination TREATMENT ▪ Change dietary/defecation habits, pharmacological, surgical ▪ Visible abnormalities ANAL FISSURE osms.it/anal-fissure PATHOLOGY & CAUSES ▪ Anal mucosa linear fissure ▪ Hard bowel movement → anal mucosa stretches → acute fissure → internal anal sphincter spasms → blood flow reduces → difficult healing → chronic fissure ▪ Midline, anteriorly/posteriorly RISK FACTORS Low fiber diet Diarrhea Previous anal surgery Anal trauma Abnormalities in internal anal sphincter Sexually transmitted infections (STIs) ▫ Human papillomavirus (HPV), herpes, chlamydia ▪ Inflammatory bowel disease (IBD) ▪ ▪ ▪ ▪ ▪ ▪ COMPLICATIONS ▪ Fecal bacteria infection SIGNS & SYMPTOMS ▪ Midline tear ▪ Pain during bowel movements → fear of defecation → constipation → harder stool → more pain ▪ Blood on toilet paper/stool DIAGNOSIS ▪ History, examination of anal region/rectum OSMOSIS.ORG 355

TREATMENT MEDICATIONS ▪ Stool softeners ▪ Topical nitrates/calcium channel blocker (e.g diltiazem) SURGERY ▪ Sphincterotomy OTHER INTERVENTIONS ▪ Proper anal hygiene ▪ Warm bath (AKA sitz bath) ▪ Muscle relaxation → increase healing mechanisms ▪ Fiber supplementation Figure 42.1 The clinical appearance of an anal fissure affecting the posterior anal mucosa. ANAL FISTULA osms.it/anal-fistula PATHOLOGY & CAUSES ▪ Abnormal communication between anal canal, perianal skin ▫ Fistula: Latin (pipe, catheter), from findo (cleave, divide, split) ▪ Foreign material in anal crypts → anal glands ducts blocked → anal abscess → pus travels to skin through tract Extrasphincteric ▪ Rectum/sigmoid colon → levator muscle ani → skin SIGNS & SYMPTOMS ▪ Skin excoriations, pus/serous fluid/feces draining from skin-opening, bleeding, itching, pain, redness, swelling TYPES Intersphincteric ▪ Internal anal sphincter → space between internal, external anal sphincters (AKA intersphincteric plane) → skin Transsphincteric (U-shaped fistula) ▪ Internal anal sphincter → intersphincteric plane → external anal sphincter → skin Suprasphincteric ▪ Internal anal sphincter → puborectalis muscle → space between puborectalis, levator ani muscle → skin 356 OSMOSIS.ORG DIAGNOSIS OTHER DIAGNOSTICS ▪ Anal examination → delineate course of fistula TREATMENT SURGERY ▪ Drain infection → eradicate fistulous tract → preserve anal sphincter function → avoid recurrences

Chapter 42 Rectal & Anal Pathology Figure 42.2 Surgical wound following removal of an anal fistula. HEMORRHOID osms.it/hemorrhoid PATHOLOGY & CAUSES ▪ Anal cushions hypertrophy due to supportive tissue deterioration TYPES Internal ▪ Affecting hemorrhoidal venous cushions above dentate line ▫ Grade I: bleed but not prolapse ▫ Grade II: prolapse on straining but reduce spontaneously ▫ Grade III: prolapse on straining, require manual reduction ▫ Grade IV: spontaneous, irreducible prolapse External ▪ Affecting hemorrhoidal venous cushions below dentate line RISK FACTORS ▪ Constipation (low fiber diet), strenuous defecation, diarrhea, prolonged sitting, aging, increased intra-abdominal pressure, pregnancy, intra-abdominal mass, ascites, portal hypertension COMPLICATIONS Internal hemorrhoids ▪ Bleeding with bowel movements ▪ Prolapsing ▪ Incarceration, strangulation → pain ▪ Mucus deposits on perianal tissue → itching External hemorrhoids ▪ Bleeding ▪ Acute thrombosis → acute pain ▪ Itching ▪ Hygiene difficulties SIGNS & SYMPTOMS ▪ Itching ▪ Bleeding associated with bowel movement → bright red blood on toilet paper ▪ Pain ▪ Mucous discharge ▪ Perianal mass in case of prolapse OSMOSIS.ORG 357

DIAGNOSIS DIAGNOSTIC IMAGING ▪ Anoscopy for internal hemorrhoids OTHER DIAGNOSTICS TREATMENT MEDICATIONS ▪ Stool softeners ▪ Topical, systemic analgesics SURGERY ▪ Anal, perianal inspection ▪ Digital rectal examination ▪ Sclerotherapy, rubber band ligation, infrared coagulation OTHER INTERVENTIONS ▪ Increase fiber, fluid intake Figure 42.3 The histological appearance of an excised hemorrhoid. There is fibromuscular hyperplasia and numerous dilated vascular spaces. Figure 42.4 External appearance of grade 2 hemorrhoids. RECTAL PROLAPSE osms.it/rectal-prolapse PATHOLOGY & CAUSES ▪ Partial/total slip of rectal tissue through anal orifice RISK FACTORS ▪ Constipation, diarrhea, pregnancy, pelvic floor damage COMPLICATIONS ▪ Mucous discharge, bleeding, fecal incontinence, constipation, rectal ulceration 358 OSMOSIS.ORG SIGNS & SYMPTOMS ▪ Mass protruding through anus ▫ After defecation; when sneezing/ coughing; when walking → pain, rectal bleeding, incontinence

Chapter 42 Rectal & Anal Pathology DIAGNOSIS OTHER DIAGNOSTICS ▪ Physical examination ▫ Prolapse clearly evident TREATMENT SURGERY ▪ Sutures/mesh slings to anchor rectum to posterior wall of pelvis (sacrum) ▫ Open or laparoscopic ▪ Rectosigmoidectomy ▫ Part of rectum and sigmoid pulled through anus and removed, reanastomosis of remaining rectum to colon ▫ Usually reserved for severe prolapse/ non-candidates for open/laparoscopic procedure OTHER INTERVENTIONS Figure 42.5 A complete rectal prolapse. ▪ High fiber diet, enemas, suppositories (to avoid constipation/straining) ▪ Kegel exercises may help limit progression OSMOSIS.ORG 359