常见肛周疾病commonanorectalppt课件

1、sandra j. beck, m.d., facs, fascrsassociate professor of colon and rectal surgeryuniversity of kentucky medical centerdisclosureslnonelanatomy of the anal canal and perianal spaceslbenign anal rectal disease abscess and fistula fissure hemorrhoidslanatomy pelvic and perirectal spacesanatomy of anal

2、canalretrorectal spacewaldeyers fasciasupralevator spacelevator ani muscledeep postanal spacesuperficial postanalspaceperitoneumlevator ani m.puborectalis m. deep external sphincter m.internal sphincter m.transverse septumsupralevatorspaceischioanal spaceintersphinctericspaceperianal spaceanal canal

3、 anal canalanal transitionalzonecolumn ofmorgagnidentate lineanal cryptanal glandanodermpatient complaintsanal painbleedingdrainagetime coursefissureknifelike pain with bmpassing glass brick, throbingpain with bm:minutes to hoursblood on toilet paperno drainagesmall tag or “hemorrhoid”hemorrhoidacut

4、e or chronicbleeding itching burning sudden swelling, +/- painprolapsedifficulty with hygienepain rarely knifelikeabscessgenerally acute minimal bleedingpain swelling over largearea not associated with bm+/-purulent drainagerapid increase in sizelcryptoglandular abscess most common infection in the

5、glands at the dentate line lother causes crohns and ulcerative colitis tuberculosis and actinomycoses malignancy foreign bodies, prostate surgery or radiationfistula descriptionlclock description does the anus tell time? relies on description of patients position: supine, lateral, prone and relative

6、 landmarkslanatomic description: more consistent pubic bone defines anterior coccyx define posterior right and left *if terms be incorrect, then statements do not accord with facts; and when statements and facts do not accord, then business is not properly executed. confucius 1 tailboneright anterio

7、rright posteriorleft anteriorleft posteriorrightleftpubic bonelthere is an area of induration and erythema in the right posterior quadrant that is likely an abscess that has spontaneously drainedlfour types based on space involvedperianal - 19-54%intersphincteric - 20-40%ischioanal - 40-60%supraleva

8、tor 2% or lessmost commonraresupralevatorabscessperianal abscessischioanal abscessintersphinctericabscesssupralevatorspaceintersphinctericspaceischioanal spacehorseshoe abscessldiagnosis - usually straightforward erythema and pain over affected area fluctuanceltreatment incision and drainage +/- exc

9、ision of small amount of overlying skin initial packing for hemostasis drainage catheter (pezzer) or pack wound attention to good hygiene and control blood sugar antibiotics if immunocompromised, obese or diabeticsmall radial incisionshort distance from anus feel for soft spotplace drain and trim av

10、oids packingfollow up in 7-10 days to remove draincatheter typeslpezzer catheterlsolid mushroom top so stays inlless tissue ingrowthlmalecotlallows tissue ingrowthlmore painful to removeperi anal abscess - ? antibioticslnot usually indicated if there is adequate drainagelindicated for patients with:

11、 obesity diabetes imunocompromised extensive large abscess or recurrent abscessldefinition abnormal connection between two epithelial surfaces.lclassification: parks: defines fistula by course of tract goodsalls ruleldiagnosisltreatment goals optionshow does patient present?lmay have had a history o

12、f abscess lhistory of crohns diseaselmay present at the same time as abscesslcomplain of intermittent increase in pain/swelling followed by spontaneous drainagelchronic localized area of irritation or ulcer “pimple near my anus keeps coming back”posterioranteriorfistula in ano: surgical diseaselrefe

13、r to colon and rectal surgeon or general surgeonlreassure patient rarely cancer, most do not need a colostomylif suspect crohns gain control of perianal sepsis then complete full workup and staginglgoals of therapy get rid of the fistula/connection preserve continencesurgical optionslprimary fistulo

14、tomy mainly for low, superficial fistula risk of fecal incontinencelfibrin glue/fistula plug utilizes substrate as scaffold to fill tract does not involve cutting musclelcutting or draining setons for deeper tracts that involve significant muscle risk of fecal incontinencelrectal advancement flaplla

15、teral internal fistula transection newer procedure. no foreign substrate cuts fistula tract, not muscleldefinition a painful linear ulcer situated in the anal canal and extending from just below the dentate line to the margin of the anus overlie the lower half of the internal sphincter 73.5% are pos

16、terior 16.4% are anterior 2.6% both anterior and posteriorlacute fissure results from trauma to the anal canal most commonly from a large fecal boluslsecondary changes of chronic fissure include sentinel pile or skin tag at the distal end hypertrophied anal papilla-swelling, edema and fibrosis near

17、the dentate line fibrosis of the internal sphincter at the base lperpetuating factors in chronic fissure persistent hard bowel movement abnormal high resting pressure in the internal anal sphincter increased pressure in the sphincter causes a decrease in blood flow, preventing healing of the fissure

18、lpain is the main symptom sharp, cutting or tearing during defecation duration is few minutes to hourslbleeding bright red and scantlskin tag lmucous discharge resulting in itching ldiagnosis often made on history alonelinspection gently spread the buttocks and the fissure becomes apparentltriad of

19、chronic anal fissure sentinel pile hypertrophied anal papilla anal ulcerlintersphincteric abscesslpruritus anilfissure from inflammatory bowel diseaselcarcinoma of the anuslinfectious perianal conditionslleukemic infiltration lincrease dietary fiberllocal anesthetic to prevent spasmlnitroglycerin or

20、 nifedepine ointment not commercially available must be mixed by pharmacistlwarm tub soaksl4-6 weeks of treatmentlindicated on chronic non-healing anal fissure and fissure that is refractory to medical therapy lateral internal sphincterotomy forces the muscle to relax v-y anoplasty flap allow covera

21、ge of fissure with healthy tissuelwhat are they?lwhere are they?lwhy do they become symptomatic?lclassification?lhow do you treat them?lcan they be avoided?lspecialized highly vascular cushions consisting of discrete masses of thick sub mucosa that contain blood vessels, smooth muscle and connective

22、 tissuelaid in anal continencelinternal hemorrhoids 3 major bundles left lateral, right anterior and right posterior above the dentate line blood drains into the superior rectal vessels then into the portal circulationlexternal hemorrhoids below the dentate line blood drains through the inferior rec

23、tal veins to the pudendal veins on into the iliac veinslchronic constipationldiarrhealtrauma to the hemorrhoids during defecation cause the most common symptoms pain generally not “knife-like” itching burning bleeding l1st degree bulge into the lumen l2nd degree prolapse with bowel movement but redu

24、ce spontaneouslyl3rd degree prolapse spontaneously and require manual reductionl4th degree permanently prolapsed hemorrhoids that cannot be reducedlthorough physical exam to determine severity and rule out other pathology refer for surgical evaluation if white or discolored, firm or fixedldetermine

25、if the problem is internal, external or bothlassess the symptom complexltopical agents: proctofoam, anusol hc analpram, proctosol creamlconservative therapy bulk agents i.e. high fiber fruits, vegetables, oat bran, psyllium increase water intake avoid caffeinated beverages avoid prolonged sitting on

26、 the commode warm tub soakslrubber band ligation performed in the office indicated for grade 1 and 2 internal hemorrhoids band is applied through an anoscope at the top of an internal hemorrhoid severe perianal sepsis classic triad delayed anal pain urinary retention fever linfrared photocoagulation

27、 indicated in 1st degree hemorrhoids causes photocoagulation of small vessels performed in office or “hemorrhoid relief center” minimal painlhemorrhoids are severely prolapsed and require manual replacementlpatients fail to improve after multiple applications of non-operative treatmentlhemorrhoids a

28、re complicated by associated pathology such as ulceration, fissure, fistula, large hypertrophied anal papilla or extensive skin tagslmost can be performed with local and iv sedationlprone/kraske position is the bestlinfuse the area with local anesthetic with epinephrine for hemostasislfleets enema 1

29、-2 hours priorlno antibiotic prophylaxis is necessarylnot for every hemorrhoidlideal for grade 2 and 3 with minimal external componentlprevents prolapse and thus less trauma to hemorrhoid with bowel movementlbenefits less pain as compared to traditional closed hemorrhoidectomy less blood loss during the procedure less chance of anal stenosislrisks if staple placed too low severe chronic pain and incontinence if staple line placed too high failure to relieve symptoms of hemorrhoids hemor