Anal conditions

4th stage

surgery
Part 6
د.أحمد ابراهيم

4/10/2015

Pruritis Ani




This is intractable itching around the anus. Usually the skin is reddened hyperkeratotic and may become cracked and moist.
The causes are numerous:
pus,
polypus,
parasites,
piles,
psyche’.
-Lack of clean lines, excessive sweating, and wearing rough or woolen underclothing are common causes
-An anal or perianal discharge which renders the anus moist
-The causative lesions include an anal fissure, fistula in ano, prolapsed internal or external haemorrhoids, genital warts and excessive ingestion of liquid paraffin.
-A mucous discharge is an intense pruritic agent and a polyp can be the cause
-A vaginal discharge, especially due to the Trichomonas vaginalis
-Parasitic causes: Threadworms in Children should wear gloves at night, less they scratch the perianal region and are reinfested.
-Scabies and pediculosis pubis may infest the anal region.
-Allergy is sometimes the cause, in which case there is likely to be a history of other allergic manifestations, such as urticaria, asthma or hay fever.
-Antibiotic therapy may be the precipitating factor.
-Skin diseases localised to the perianal skin : psoriasis, lichen planus and contact dermatitis.
-Bacterial infection. Intertrigo due to a mixed bacterial infection.
-A psychoneurosis. neurotic individuals become so immersed in their complaint that a pain pleasure complex develops, the pleasure being the scratching.
-Diabetes can sometimes present with pruritus ani and the urine should be tested in all patients.
TREATMENT :
The cause is treated
Other methods include the following :
1- Hygienic measures:
Cotton wool should be substituted for toilet paper.
Soap is avoided .
If there is much anal hair trapping the moisture and discharge, shaving can be very helpful.
2-Hydrocortisone.
in cases with dermatitis, and only in cases with dermatitis, prednisolone, applied topically.
3-Operative treatment
This may be necessary for a concomitant lesion of the anorectum which is thought to initiate or contribute to the pruritis, Otherwise,surgery is not indicated


Hypertrophied Anal Papilla
-Anal papillae present at the dentate line
-As these papillae are present in 60 per cent of patients examined proctologically, they should be regarded as normal structures
-Anal papillae can become elongated, as they frequently do in the presence of an anal fissure
-Occasionally, an elongated anal papilla may be the cause of pruritus.
-An elongated anal papilla associated with pain and/or bleeding at defecation is sometimes encountered in infancy.
-Haemorrhage into a hypertrophied anal papilla can cause sudden rectal pain.
TREATMENT :
Using a proctoscope, elongated papillae without haemorrhoids should be crushed and excised after injecting the base with local anaesthetic.

Proctalgia Fugax

-This disease is characterised by attacks of severe pain arising in the rectum, recurring at irregular intervals and apparently unrelated to organic disease.
-The pain is described as cramp-like, often occurs when the patient is in bed at night, usually lasts only for a few minutes and disappears spontaneously.
-It may follow straining at stool, sudden explosive bowel action or ejaculation. It seems to occur more commonly in patients suffering from anxiety or undue stress, and also it is said to afflict young doctors.
-The pain may be unbearable.
-It is unpleasant, incurable, but fortunately harmless and gradually subsides.

Non Malignant Strictures

Congenital
Patients who have had an operation for imperforate anus in infancy may require periodic anorectal dilatation.
Spasmodic
An anal fissure causes spasm of the internal sphincter.
Rarely, a spasmodic stricture accompanies secondary megacolon , possibly due to chronic use of laxatives.
Organic
Postoperative stricture :
sometimes follows haemorrhoidectomy performed incorrectly, low coloanal anastomoses, especially if a stapling gun is used, can narrow down postoperatively.
Irradiation stricture :
Senile anal stenosis :
a condition of chronic internal sphincter contraction is sometimes seen in the aged. Increasing constipation is present with pronounced straining at stool.

Inflammatory bowel disease :

Stricture of the anorectum also complicates ulcerative proctocolitis and most commonly large bowel Crohn’s disease, A carcinoma should be suspected if a stricture is found, until a biopsy is obtained.
Endometriosis :
of the rectovaginal septum may present as a stricture. There is usually a history of frequent menstrual periods with the appearance of severe pain during the first 2 days of the menstrual flow
Neoplastic :

Clinical features

1-Increasing difficulty in defecation is the leading symptom
2-The patient finds that increasingly large doses of aperients are required, and if the stools are formed, they are ‘pipe-stem’ in shape.
3-In cases of inflammatory stricture, tenesmus, bleeding and the passage of mucopus are superadded.
4-Sometimes the patient comes under observation only when subacute or acute intestinal obstruction has supervened.
Rectal examination.
The finger encounters a sharply defined shelf-like interruption of the lumen
A biopsy of the stricture must be taken


TREATMENT :
Prophylactic
-The passage of an anal dilator during convalescence after haemorrhoidectomy greatly reduces the incidence of post­operative stricture
-Dilatation by bougies For anal and many rectal strictures at regular intervals is all that is required
Anoplasty
This technique is particularly useful for postoperative strictures.
Colostomy
-Colostomy must be undertaken when a stricture is causing intestinal obstruction, and in advanced cases of stricture complicated by flstulae in ano.
-Rectal excision and coloanal anastomosis
-When the strictures are at or just above the anorectal junction, and with a normal anal canal, but irreversible changes necessitate removal of the area., Eg. post irradiation.
Malignant lesions of the anus and anal canal
Carcinoma of the anus differs from carcinoma of the rectum in histological structure, behavior and types of treatment.
This is mainly because of its accessibility, its sensitivity and its abundant lymph drainage, both superficial and deep.
70% of anal tumours arise in the anal canal.
30 % are carcinomas of the anal verge.
Metastases may develop in the inguinal lymph nodes , if the tumour below the dentate line or in the paraaortic lymph nodes if the tumour above dentate line .

Pathological types

Squamous cell carcinoma : Because of its superficial situation, the presence of this lesion is frequently recognized by the patient, who often presents early.
Basaloid carcinoma : is a form of nonkeratinising squamous carcinoma. It can metastasise to lymph nodes and can be highly malignant. It is not very sensitive to irradiation.
Mucoepidermal carcinoma : This tumour arises near the squamocolumnar cell junction and is of average malignancy. It is radiosensitive.
Basal cell carcinoma : These are ‘skin tumors' and behave accordingly.


Malignant melanoma :
Melanoma of the anus presents as a bluish-black soft mass that is confused with a thrombotic pile, and therefore unfortunately incised, Such trauma, followed by the trauma of defecation, incites the tumour to rapid metastasis.
Left undisturbed, it ulcerates and the colour of the tumour changes from blue to black.
The inguinal lymph nodes are soon involved.
Unless a melanoma is excised at an early stage,
it disseminates by the bloodstream.
The tumour is radioresistant and has a very poor prognosis
Anal intraepithelial neoplasia (AIN) :
This may rarely affect the anal region and may be part of a more widespread lymphomatous condition.
Clinical features :
1-Anal cancer can occur at almost any age, but is usually found in the 6th and 7th decades.
2-It is a rare condition, accounting for approximately 2 per cent of all colorectal cancers.
3-Symptoms include rectal bleeding, mucus discharge, tenesmus, the sensation of a lump in the anus and a change in bowel habit
4-Occasionally, a patient may present with a mass in the inguinal region due to metastatic lymph nodes.
5-Rectal examination may reveal an ulcerating, hard, tender, bleeding mass in the anal canal or at the anal verge.
6-The lesion may fungate through the anal canal and appear on the anal skin, or present through a chronic anal fistula.

Predisposing conditions :

1-There appears to be a relationship between anal condylomata caused by the human papilloma virus, particularly type 16, and anal cancer.
2-The disease is more prevalent in patients infected with the human immunodeficiency virus .
3-Higher incidence of anal cancer in patients with Crohn’s disease.
TREATMENT :
Historically, early anal margin tumours were treated by local excision and anal canal tumours by abdominoperineal excision
Carcinoma of anal verge :
Nowadays, primary treatment is by chemoradiotherapy [combined modality therapy (CMT), the chemotherapy usually including a combination of 5-fluorouracil (5-FU) with mitomycin C or cisplatin.
Carcinoma of anal canal :







One of two lines
1-Abdominoperineal resection
Resection of anal canal and rectum with terminal colostomy.
2-Chemo-radation
A coarse of combination of chemotherapy followed by raddation , residual tumour after 4-6 weeks A-P resection done .

SH.J