Pilonidal Sinus
Surgical Options:
- Excision → Rhomboid/Limberg flap (for complex cases).
- Bascom's technique.
- Karaydakis surgery.
Hemorrhoids (Piles)
Definition
- Dilated vascular channels bleeding from sinusoids (cushions).
- Most common cause of bleeding per rectum (P/R).
- 1° hemorrhoids at 3, 7, 11 o'clock positions
- Internal hemorhoids
Clinical Features:
- Painless bleeding P/R
- Constipation.
- Painful if:
- External hemorrhoids
- below dentate line
- Self limiting
- Squamous epithelium
- Black current apperance d/t repeated thrombosis
- Thrombosed (Meleney's 5-day self-healing lesion, felt on DRE).
Investigation
- IOC: Proctoscopy.
Grades & Management
- Banding is preferred for Internal hemorrhoids
Grade | Features | Management |
Grade I | • Only bleeds • no prolapse | • High fiber diet + increased fluid intake • Laxatives, Sitz bath |
Grade II | • Prolapse • but spontaneously reduces | • Grade I measures, • Banding/Sclerotherapy |
Grade III | • Prolapse; • manually pushed inside | Surgical Hemorrhoidectomy • Open [Milligan-Morgan] • Closed [Ferguson] • Stapled Hemorrhoidopexy (TOC) • DG-HAL (Doppler-Guided Hemorrhoidal Artery Ligation) • Milli de hemorrhoid → Open aki • but Ferguson nte hemorrhoid → arodum paranjilla |
Grade IV | • Remains prolapsed • (cannot be reduced) | Surgical options (same as Grade III) |
Complications of Hemorrhoid Surgery
- Urinary Retention: m/c complication.
- Reactionary hemorrhage.
- Pain.
- Stenosis.
- Incontinence.
- Recurrence.
Anal Fissure
Definition
- Breach in anal epithelium.
m/c Site
- Posterior midline.
Clinical Features
- Painful bleeding P/R.
- Constipation.
- Skin tag/sentinel pile (in chronic cases).
- Chronic Fissure: Duration >4 weeks.
- Avoid DRE or proctoscopy
- As it is painful
Management
- First-line (Conservative):
- Lifestyle changes.
- Laxatives.
- Local xylocaine, CCB cream.
- Surgical (if medical fails):
- Lateral anal sphincterotomy
- Anal advancement flap.
Rectal Prolapse
Types & Management
Partial Thickness Prolapse (Mucosal)
- Features:
- Only mucosal prolapse.
- Common in children due to incomplete sacral curve.
- Management:
- First Episode:
- Digital repositioning.
- Recurrent:
- Thiersch wiring.
- Sclerotherapy.
Full Thickness/Complete Prolapse
Features:
- All layers of rectum prolapse.
- Common in adults due to weak pelvic floor.
Management:
Perineal Procedures:
- Easy, fewer complications.
- High recurrence rate.
- Thiersch repair (purse-string sutures).
- Delorme's repair (plication of prolapse).
- Altemeier (perineal rectosigmoidectomy).
- Mnemonic:
- Thurish in Purse;
- Altermeier → Ultimate resection → Through perinium, resect out rectum and sigmoid
- Deloreme → Deal locally
Abdominal Procedures:
- More difficult, increased complications.
- Least recurrence rate.
- Ripstein rectopexy.
- Weil rectopexy.
- Frykberg Goldman (Resection rectopexy).
- Mnemonic: Rip () the Gold () Weil () (Abdomen)
Anorectal Malformations (ARM)
Level of Anomaly
- High Anomaly:
- Male: Rectovesical fistula.
- Female: Rectovaginal fistula.
- Low Anomaly:
- Male: Anal stenosis.
- Female: Anal agenesis (with perineal fistula).
- Miscellaneous:
- Female: Persistent cloacal anomaly (common channel for rectum, vagina, urethra).
Anorectal malformation associations
- VACTERL
- Vertebral, Anorectal, Cardiac (m/c), Tracheoesophageal fistula, Renal, Limb defects
- CURARINO syndrome
- ARM + Sacrococcygeal teratoma
Similar
- Goldenhar Syndrome
- Oculoauriculovertebral spectrum
- Features
- Hypoplasia of:
- Malar
- Maxillary
- Mandibular regions
- Macrostomia
- Microtia
- Preauricular and facial skin tags
- Hemivertebrae
- Usually cervical
- Mental handicap
- Cardiac, renal, and CNS anomalies
- Ocular
- Dermoid
- Upper lid notching / coloboma
- Microphthalmos
- Disc coloboma
Investigation (Invertogram)
- Timing: Done 24 hours after birth.
- Procedure:
- Patient inverted, metallic marker placed at anal opening.
- X-ray taken to measure distance from gas bubble (rectum) & marker.
- Interpretation:
- <2 cm: Low anomaly.
- >2 cm: High anomaly.
- Note: MRI is m/c used IOC now for detailed anatomy.
Management
- Surgery to bring the rectum down (anoplasty/anorectoplasty).
Anorectal Abscess & Fistula
Source
- Infected anal glands.
- Location: Close to the dentate line.
Perianal Abscess
Clinical Features
- Pain & fever.
Management
- Incision & drainage.
Complication
- Perianal fistulae (if improperly managed or recurring).
Perianal Fistula
Cause
- Commonly a complication of perianal abscess (unresolved).
Clinical Features
- Pus discharge per rectum (P/R).
Goodsall's Rule
- Imaginary line drawn transversely through the anal verge.
- Fistulae anterior to line: Usually straight tracts to anterior internal anal sphincter.
- Fistulae posterior to line: Usually curved tracts to posterior anal sphincter
- Exception:
- Long anterior fistula (>3 cm) may curve to posterior midline opening.
Classification & Imaging
- Park's Classification:
- Describes relationship of fistula to sphincter muscles.
- Park and do anal fistula
- IOC: MR fistulogram (to map tract for surgery).
Watercan Perineum
- Multiple perianal fistulae with multiple external openings.
- N. Gonorrhea
- Causes:
- Crohn's disease (m/c).
- Trauma.
- Tuberculosis.
- Cancer.
- Immunocompromised patients.
Management (Based on Internal Opening & Complexities)
Low Fistulae (Below anorectal ring/lower sphincter)
- Procedures:
- Fistulectomy (complete excision of tract).
- Fistulotomy (opening up the tract).
- LIFT (Ligation of Intersphincteric Fistula Tract).
- VAFT (Video Assisted Fistula Therapy).
High Fistulae (Above anorectal ring/through upper sphincter)
- Procedures:
- Seton's procedure (slow cutting seton or draining seton).
- Risk: Incontinence (especially with cutting setons).
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