all an MBBS student needs to know

2. • The length of the anal canal is about 4 cm (range, 3-5 cm),
• 2/3rd of this being above the dentate line
• 1/3rd below the dentate line.

4. • SURGICAL anal canal :
Begins where the rectum
passes through
pelvic diaphragm and ends
at the anal verge
• ANATOMICAL anal canal :
At the junction of the
puborectalis portion of the
levator ani muscle and the
external anal sphincter,
and extends distally to the
anal verge.

5. • ANORECTAL RING :
-Junction between
rectum and anal canal
-Upper border of
puborectalis and external
spinchter complex
-Formed by:
Deep external
sphincter + Conjoined
longitudinal muscle +
internal spinchter
(highest part)

6. 1. -External sphincter
2. -Puborectalis muscle
3. -Internal sphincter
4. -Longitudinal
Muscle

7. •EXTERNAL SPINCTER
-Subdivided into
subcutaneous
superficial and deep
-Attached anteriorly to
perineal muscle and
posteriorly to coccyx
-voluntary muscle
(skeletal muscle) and
innervated by pudendal
nerve

8. INTERNAL SPHINCTER
• Thickened distal continuation of circular muscle coat of the
rectum and ends 0.5cm below dentate line
• Always in tonic state of contraction
• Involuntary (smooth muscle) and 2.5cm long.
• Innervated by ANS and intrinsic NANC (non-adrenergic non-
cholinergic) fibres → release of NO→ Sphincter relaxation

9. -Uneven mucosal and submucosal folds above dentate line
-Painless , it has 3 common position
(Left Lateral , Right Anterior , and Right Posterior)
-Contain vascular , muscular and connective tissue

10. BL
•Su
OOD SUPPLY
pplied by superior, middle and inferior rectal art
NOUS DRAINAGE
pper ½ of anal canal :
Superior rectal veins  tributaries of the inferior
mesenteric vein Portomesenteric venous system
Middle rectal veins internal iliac veins
wer ½ of the anal canal:
rior rectal veins + Subcutaneous perianal plexus
eries
VE
• U
1.
2.
•Lo
Infe of veins

13. EMBROLOGY
•Cloaca becomes two parts: 1) dorsal (rectum)
2) ventral (urogenital)
•Cloaca is separated from surface ectoderm of the embryo by the
cloacal membrane
•Anal canal is developed from fusion of postallantoic gut with
proctodeum.
•The junction of these is the dentate line or pectinate line.
•Anal valves of Ball are remnants of proctodeal membrane .

14.  • Divided into two main group – high and low
Depends on termination of the rectum in relation to pelvic floor
 • Low defect:
 • M=F : rectoperitoneal fistula
 • M : Rectrobulbar fistula
 • F : Rectovestibular fistula
 • easy to correct; prone to constipation
• High defect:
• Fistula into bladder neck
• difficult to correct ; prone to faecal incontinence

15. Management
• Investigation :clinical examination
Lateral prone radiography (after 24 hours)
• Treatment :
-First 24 hours : IV fluid correction and antibiotics
+ evaluate asst. abnormality
-Surgery:
 Anoplasty (low and perineal fistula)
 Early colostomy + Posterior Sagittal Anorectoplasty PSARP
 PSARP + Vaginal and urinary reconstruction (cloaca)
 Anal dilatation programme

16. • Soft cystic swelling occupying the space in front of the lower
part of the sacrum and coccyx (Hollow)
• Asymptomatic until adult life
• Difficulty to defecate due to its size
• Unlikely to be discovered unless a sinus communicating with
the exterior is present / develops as an inflammation
• Cyst easy to palpate per rectum
•Treatment -Excision
Remove cocyx-if large/child with presacral dermoid

17. POST-ANAL DIMPLE
• Fovea coccygea is a dimple in the skin beneath the tip of the coccyx
• No consequences found
PILONIDAL SINUS (Jeep disease)
Location:in the natal cleft overlying the coccyx
•One or more with a fibrous hair lying loosely within lumen
•Age 20-29 years
•Etiology:
-Congenital
-Acquired; Interdigital pilonidal sinus (hairdresser)

18. Buttock
friction+shearing
force
Broken hair drill
through the skin
Track/sinus
formation
Secondary track
spread laterally
Discharging
opening to skin
(lined granulation
tissues)
Dark-haired
After puberty till 40 years
Intermittent pain,swelling
and discharge at the
base of the spine
H/o repeated abscess that
have burst
spontaneously/have
been incised AWAY
from midline
PATHOGENESIS CLINICAL
FEATURES
Midline track

20. MANAGEMENT
CONSERVATIVE
•If symptom is minor:
Clean the tracks
Remove all hair
Regular shaving that area
Strict hygiene
ACUTE EXACERBATION
(ABSCESS)
Rest,sitz bath,local antiseptic,
broad spectrum antibiotic
Drained through small
longitudinal incision made over
abscess and off the midline +
curettage of granulation tissue and
hair
CHRONIC (SURGERY)
•Excision:
-Laying open +/- marsupilisation
-With/without 1⁰ closure
-Closure by other means:Z-plasty,
Karydakis procedure,Bascom’s
procedure

22. Definition:
•It is a dilated
to anal canal.
•CLASSIFICA
• Primary/Idi
• Secondary
pregnancy.
• Depending
– internal,interno-external and external
•LOCATION
(lithotomy position)
plexus of haemorrhoidal veins in the anal cus
TION :-
opathic haemorrhoids-familial or genetic
haemorrhoids – carcinoma of rectum, ascites
Upon the location of haemorrhoids
hion, in relation

24. • VENOUS OBSTRUCTION-Portal hypertension and varicose veins
-Pregnancy,ascites,pelvic tumor
• INFECTION
-2⁰ to trauma during defecation
• DIET
-Fibre-deficient diet (western cuisine)
• DEFECATION HABIT
-Straining
-Sitting for prolong periods on lavatory
• ANAL TONE
• AGEING

25. •
•
•
1 Never prolapse Bleeding per rectum
2 Prolapse on defecation
Spontaneous reduction
Something coming down and going
back
3 Prolapse on defecation require
manual reduction
Something coming down, bleeding,
mucus discharge, pruritis
4 Permanent prolapse Acute pain, throbbing discomfort

27. • Chronic anemia
• Ulceration
• Thrombosis and strangulation
• Fibrosis
• Portal pyaemia
• Gangrene
INVESTIGATIONS
• Per rectal examination – thrombosed or
fibrosed
• Proctoscopy or Sigmoidoscopy

28.  COMPLICATION
 -Strangulation,thrombosis and
gangrene→ analgesia
+frequent sitz bath +compression
 CONSERVATIVE
TREATMENT
 Fibre supplementation
 Increased fluid intake
 Laxatives
 Lose weight
 TREATMENT
 -Invasive therapy
 *sclerosing inj.
 *band ligation
 *cryotherapy
 *infrared photocoagulation
• Operative treatment
 -hemorrhoidectomy

29. INVASIVE THERAPY
Injection of sclerosant –
Subbmucosal injection of 5 ml of
5 % phenol in almond/arachis oil
Using Gabriel syringe at apex of
pedicle
reassessed after 8wks
Barron`s band application
 put a elastic band at the
base of pedicle
 ischemic→slough off +
bleeding (after 3 days)

30. Definition:
-Excision of the pile masses up to base.
•Indicated in Grade II and III
•It can be done by 3 methods :-
OPEN METHOD – Milligan Morgan ligature and excision
 CLOSED METHOD – Hill-Ferguson
STAPLER HAEMORRHOIDOPEXY – Non-excisional procedure
Complications of haemorrhoidectomy
•Early = Pain, Acute retention of urine, Reactionary
haemorrhage
•Late = Secondary haemorrhage, Anal stricture, Anal fissure,
Incontinence

31. ANAL
FISSURE(SYN:FISSURE-IN-
ANO)
A longitudinal split in
the anoderm of the
distal anal canal, which
extends from the anal
verge proximally
towards, but not beyond
the dentate line

32. • Superficial, small but distressing lesion
• Fissure ends below the dentate line
• Commonly occurs in the midline, posteriorly
or
anteriorly

33. • Causes
• Trauma  strained evacuation of a hard stool
(acute) Repeated passage of diarrhea (less common)
• Posterior anal fissure  perhaps relates to the
exaggerated shearing forces acting at that site during
defecation
• Anterior anal fissure  common in females (10:1) due
to lack of support to pelvic floor (following vaginal
delivery)

34. • Clinical
features• Constipation
• Severe anal pain on defecation
• Passage of fresh blood (bright red)
• Chronic fissure; characterized by:
• Hypertrophied anal papilla internally & sentinel tag
exernally (both consequent upon attempts at healing
and breakdown)
• Between them, lies the slightly indurated anal ulcer
overlying the fibres of the internal sphincter (felt as button like
depression)
• Patient may have itching secondary to irritation from
the
sentinel tag
• Discharge from the ulcer or asst. intersphincteric fistula

35. • SENTINEL TAG
• Commonly associated with fissure-in-ano of chronic
type, wherein, in the lower part of fissure, skin
enlarges and appears like guarding the fissure
• Can cause perianal haematoma, abscess formation,
and discomfort
• Chronic fissure is treated along with excision of
sentinel pile

36. • Treatmen
t
• Conservative management:
• Adequate fluid intake (6-8 glasses of liquid)
• Fiber rich diet (vegetables, fruits, brown rice)
• Bulk forming agents (psyllium husk, bran)
• Stool softeners (lactulose)
• Local anaesthetic agents (lignocaine 5%)
• Pharmacological agents (commonly nitric oxide
donors)
 Reducing spasm to relieve pain
 Increase vascular perfusion to promote healing
• Sitz bath
• Operative measures:
• Lateral anal sphincterotomy
• Anal advancement flap

37. PRURITUS
ANI
Intractable itching in and around the
anus

38. • Common, embarrasing
condition• Skin is reddened, hyperkeratotic, cracked &
moist
• Causes:
• Poor hygiene
• Anal discharge (due to
fissure/fistula/piles/warts/polyps)
• Trichomonas vaginalis infection (females)
• Parasites
• Epidermophytosis
• Allergic cause
• Skin diseases -Dermatitis/psoriasis
• Diabetes mellitus
• Psychological cause

39. • Treatmen
t • Proper cause should be assessed and treated
• Symptomatic treatment includes:
• Hygiene measures: toilet papercotton wool;
soapwater;rubpat-dried; cotton underwear; calamine
lotion; shaving
• Hydrocortisone: only in patients with dermatitis
• Strapping of the buttocks
*Surgery is only indicated if there’s a lesion of the
anorectum that is thought to initiate/contribute to
the pruritus

40. ANORECTAL
ABSCESS
infected cavity filled with pus found near the anus or rectum

41. • Usually produces a painful, throbbing swelling
in
the anal region
• Patient often has swinging pyrexia
• Subdivided according to anatomical site into
perianal, ischiorectal, submucous and pelvirectal

42. • Acute sepsis in the region of the anus is
common• Underlying conditionts include
• Fistula-in-ano (most common)
•
• Infected hematoma
• Foreign body/trauma
• Diabetes
• Immunosuppression
• Treatmentdrainage of pus + antibiotics

43. FISTULA-IN-ANO
Fistula-in-ano/anal fistula is a chronic abnormal
communication which runs outwards from the anorectal
lumen (the internal opening) to an external opening on
the skin of the perineum or buttock or vagina (women,
rare)

44. • May be found in specific conditions
like:• Crohns disease
• Tuberculosis
• Lymphogranuloma
venereum
• Actinomycosis
• Rectal duplication
• Foreign body
• Malignancy

46. • Clinical assessment:
• Determine the:
• Site of internal opening
• Site of external opening
• Presence of secondary extensions
• Presence of other conditions complicating the fistula
• Goodsalls ruleused to indicate the likely position
of the int. opening according to position of the ext.
opening (HELPFUL BUT NOT INFALLIBLE!)

47.  Full examination
under anaesthesia
should be repeated
before surgical
intervention
 Fistulotomy
 Fistulectomy
 Seton

48. HIDRADENITI
S
SUPPURATIV
A
A chronic suppurative condition of apocrine gland-bearing
skin and is a source of considerable physical and
psychological morbidity

50. • Presentatio
n• Not seen before puberty, rare after 4th decade of life
• 3x more common in women than men
• Obesity is a common association
• Lesion begin as multiple raised boils, with recurrent
lesion within the same area leading to sinus tract
formation
• Treatment
• In early stages, general measures:
• Weight reduction
• Antiseptic soaps
• Surgical intervention ranges from simple I&D to
radical excision of all apocrine gland-bearing skin 
req. closure by skin graft/rotation flap

51. ANAL
WARTS
(CONDYLOMATA ACCUMINATA)
Most common sexually transmitted anal
disease.

52. Increase incidence in:
•sexual promiscuity (esp. anal intercourse)
•immunocompromised individual (HIV-infected
individuals, transplant recipients)

53. • Presentatio
n• Many are asymptomatic
• Pruritus, discharge, bleeding & pain are usual
presenting complaints
• Penile warts or female genital warts may be present
• Treatment
• Local application of 25% podophyllin cream
• Surgical excision under local/regional/general
anaesthesia

54. ANAL
STENOSIS

55. • May be spasmodic or
organic
• Spasmodic:• Anal fissure causes spasm of the anal sphincter
• Organic:
• Postoperative stricture (hemorrhoidectomy)
• Irradiation stricture (chemoradiation for anal
carcinoma/ pelvic tumors)
• Senile anal stenosis
• Inflammatory bowel disease ;Crohns/UC
• Neoplastic
• Treatment:
• Biopsy must be taken to rule out malignancy
• Can usually be managed by regular dilatation
• Severe anal stenosis may require an anoplasty

56. Multifocal virally induced dysplasia of the perianal /intra-anal
epidermis which is aassociated with HPV

57. • At-risk group:
• HIV patients
• Immunocompromised patients
• Patients with extensive anogenital condylomata
• Women with h/o other genital intraepithelial
neoplasia (VIN & CIN)

58. MALIGNANT
TUMOR
Rare!
Accounts for <2% of all large bowel
cancers

59. • Rare
• Incidence rate is 0.65 per 100,000
• Usually a squamous cell carcinoma
• Associated with HPV
• More prevalence in patient with HIV infection
• May affect anal verge or anal canal
• Lymphatic spread is to inguinal LN
• Treatment: chemotherapy
• Major ablative surgery is required if the above
fails

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