proctologie

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PROCTOLOGIE
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Anatomia canalului anal
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Anatomie
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Musculatura anorectala
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Hemoroizii

• Hemoroizii sunt localizati in tesutul submucos al
  canalului anal.
• Hemoroizii sunt clasificati ca interni si
  externi.
• Hemoroizii interni au ca origine tesut vascular
  ce provine din plexul hemoroidal submucs. Sunt
  localizati deasupra liniei pectineale fiind
  acoperiti de mucoasa.
• Hemoroizii externi sunt dilatatii ale vaselor ce
  provin din plexul hemoroidal inferior. Sunt
  localizati sub linea pectineala fiind acoperiti
  de epiteliu scuamos sau tegumente perineale.

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Clasificarea hemoroizilor interni

• Gradul 1 are loc protruzia hemoroizilor in
  lumenul canalului anal pe perioada defecatiei.
• Gradul 2 are loc protruzia dilatarilor
  hemoroidale in afara marginilor canalului anal pe
  perioada defecatiei dar care se reduc spontan.
• Gradul 3 protruzia hemoroizilor areloc la fel ca
  la gradul doi, dar nu se mai reduc spontan dupa
  defecatie ci numai prin manevre de taxis.
• Gradul 4 protruzia hemoroizilor in afara
  marginilor canalului anal este permanenta si nu
  se mai pot reduce.

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Distributia hemoroizilor interni pe grupuri

• Cu pacientul in pozitie geinecologica
• Grupul hemoroidal lateral stanga, localizat la
  ora 3.
• Grupul hemoroidal posterior dreapta, localizat
  intre orele 7 si 8.
• Grupul hemoroidal anterior dreapta, localizat
  intr orele 10 si 11.
• Intre aceste grupuri, pot fi vazute alte grupuri
  accesorii.

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Tablou clinic

• Simptomatologia
• Sangerare(rectoragie) de cele mai multe ori
  primul simptom gt anemie
• Prolapsul hemoroidal gt durere
• Examinare
• Hemoroizi externi - inspectia
• Tuseul rectal
• Anuscopia
• Rectosigmoidoscopia exclude patologoa
  inflamatorie si maligna.
• Materiile fecale trebuie examinate pentru
  sangerere oculta.

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Diagnostic diferential

• Carcinoma of the colon and rectum
• Diverticular disease
• Adenomatous polyps
• Ulcerative colitis
• Rectal prolapse
• Perianal condylomas
• Anorectal tumors

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Complications

• Irreducible prolapsed internal hemorrhoids

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Complications

• Irreducible prolapsed internal hemorrhoids

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Complications

• Hemorrhoids thrombosis
• Septic embolia
• Iron deficiency anemia
• Profuse bleeding if the hemorrhoids serve as a
  portosystemic shunt in portal hypertension.

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Treatment

• Medical treatment
• Local measures
• Dietary advices
• Injection treatment
• Sclerotherapy
• Rubber band ligation
• Cryosurgery
• Hemorrhoidectomy
• Other operative procedures
• Anal dilation
• Infrared coagulation
• Bipolar diathermy

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Treatment
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Treatment
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Treatment

• Rubber band ligation

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Anal fissure

• An anal fissure is a tear of the skin-lined part
  of the anal canal, the area from the pectinate
  line to the anal verge.
• Most anal fissure initiate from passage of a
  large stool.
• The majority of the fissures occur in the
  posterior midline.
• Other fissures occur secondary to Crohns
  disease, chronic ulcerative colitis,
  tuberculosis, syphilis, leukemia.

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Anal fissure
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Clinical findings

• Symptoms and signs
• Rectal pain related to defecation
• Bleeding
• Constipation
• Spasm of sphincters
• Anal tenderness
• Ulceration of anal canal
• Sentinel pile
• Special examination
• Small-caliber anoscope
• Sigmoidoscopic examination

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Treatment

• Medical treatment
• Dietary advices
• Topical agents nitroglicerine, nifedipine
• Warm sitz baths
• Surgical treatment
• Lateral internal sphincterotomy
• Anal dilation
• Excision of the anal fissure

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Surgical treatment

• Internal sphincterotomy

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Surgical treatment

• Internal sphincterotomy

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Surgical treatment

• Fissurectomy and posterior sphincterotomy

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Surgical treatment

• Fissurectomy and posterior sphincterotomy

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Anorectal abscess

• Anorectal abscess results from the invasion of
  the pararectal spaces by pathogenic
  microorganisms.
• A mixed infection usually occurs Escherichia
  coli, Proteus, streptococci, staphylococci,
  anaerobes.
• The most common cause is infection extending from
  an anal crypt.

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Anorectal abscess

• Classification
• Perianal abscess lies immediately beneath the
  skin
• Ischiorectal abscess
• Retrorectal abscess
• Submucous abscess
• Marginal abscess
• Pelvirectal abscess
• Intermuscular abscess

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Clinical findings

• Pain related to sitting and walking
• Inspection discloses external swelling, with
  redness, induration and tenderness.
• Systemic sepsis fever for deeper abscesses.

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Complications

• Extension into other adjacent anatomic spaces.
• An anaerobic infection can spread extensively.

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Treatment

• Prompt incision and adequate drainage.
• Antibiotics

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Anorectal fistulas

• Chronic purulent discharge from a para-anal
  opening.
• A fistula must have, at least two openings
  connected by a hollow tract.
• They occur after an anorectal abscess.

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Classification

• Intersphincter fistula

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Classification

• Transsphincteric fistula

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Classification

• Suprasphincteric fistula

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Clinical findings

• Symptomos and signs
• History of a recurrent abscess
• Intermitent or constant drainage
• On palpation, a cord-like tract can be felt
• Special examinations
• Digital rectal examination
• Anoscopia
• Fistulography

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Treatment

• Fistulotomy

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Treatment

• Unroofing fistula

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Treatment

• Curettage and control of hemorrhage