Diseases of rectum and anal canal

1. Diseases of Rectum and Anal
Canal
Prof. G. Bandyopadhyay
Professor
Deptt. of Surgery
Medical College, Kolkata

2. Anatomy
Rectum – distal part of gastrointestinal
tract
It´s about 12 – 18 cm long and it´s divided into
three parts:
1. proximal part
2. middle part
3. distal part ( anal canal )

5. Anatomy contd.
Blood supply : 1. superior rectal artery
( inferior mesenteric artery )
2. two middle rectal arteries
( internal iliac artery )
3. two inferior rectal arteries
( internal pudendal artery )
Internal rectal venous plexus - lies in the submucosa of the anal canal
above the level of the dentate line ( internal haemorrhoids)
External rectal venous plexus - lies under the skin of the anal canal
below the dentate line ( external haemorrhoids )

7. Congenital abnormalities
Imperforate anus – one infant in 4500-5000
A. Low abnormalities : anal stenosis ( treatment-dilatation )
anal membrane - anus is covered
with a thin membrane (treatment-incision )
B. High abnormalities : ano – rectal agenesis ( 80-85 % ),
often with recto-urethral
or recto - vaginal fistula
rectal atresia – anal canal
is normal but ends blindly above
the pelvic floor

8. Congenital abnormalities contd.
Examination : inspection,
X-ray picture ( infant is held
upside down with the coin or metal button
in the site of the anus and the gas in the
rectum will rise to the top and indicate
the distance )
Treatment : operation
incision, dilatation, colostomy,
reconstruction of the anorectum

9. Fissure-in-ano
- longitudinal ulcer in the distal part of anal canal
The site of location: - mid-line posteriorly - 80%
- mid-line anteriorly - 10%
- lateral – 10 % ( Crohn´s disease )
Ethiology – unknown ( passage of a hard stool )
- resting anal pressure is raised, but this may be due
to secondary sphincter spasm induced by pain
Two types: 1. acute
2. chronic ( hypertrophic anal papila and
sentinel tag )

10. Fissure-in-ano contd.
Symptoms : pain, bleeding,
pruritus,constipation,discharge
Management :
1. conservative ( acute) - sitz baths, laxatives,
anal dilatation, local creams
2. operation ( chronic) - excision of fissure,
posterior or lateral sphincterotomy
to reduce the high resting anal pressure

12. Haemorrhoids ( Piles )
Haemorhoids ( the dilatated rectal venous plexus )
consists of an internal and external component
( haemorhoidal disease ).
- very frequent disease
Etiology - hereditary ( weakness of the vein
walls )
- higher pelvic pressure ( pregnancy ),
- constipation, straining at stool

13. Haemorrhoids contd.
Symptoms : bleeding, prolapse,
pruritus, pain, discharge
Diagnosis: inspection - at 3,7 and 11
o´clock in litothomy position
rectoscopy, anoscopy
Complications : bleeding, thrombosis,
inflammation

14. Haemorrhoids cond.
Classification: 4 degrees
I. degree : occasional bleeding only
II. degree : prolapse after defecation with
spontaneous reposition
III. degree : prolapse needs
to be replaced manually
IV. degree : permanent prolapse with
inflammation, thrombosis etc.

15. Haemorrhoids contd.
Management :
A. conservative : sitz baths, local creams
and suppositories
B. semiconservative : injection sclerotherapy,
infrared coagulation,
rubber band ligation

16. Haemorrhoids cotd..
C. Operative treatment :
•
- Haemorhoidectomy
•
-open/closed
Stapled hemorrhoidectomy/haemorrhoidopexy
-PPH (procedure for prolapsed haemorrhoids)
Adv- no external skin wound, recovery
is rapid and relatively pain free
Disadv.-recurrence rate higher,costly

17. Haemorrhoids cotd..
•
Complications of PPH
•
•
•
•
•
•
•
Rectal perforation
Recto-vaginal fistula
Severe pelvic sepsis
Anastomotic dehiscence

20. Internal
haemorrhoids
external
haemorrhoids

21. PPH device

22. PPH procedure

23. Peri-anal Abscess and Fistula
Peri-anal abscess and fistula are two phases of the same
disease.
Abscess - acute phase
Fistula – chronic phase
Etiology :
- majority of abscesses originate in the
intersphincteric space from infection
of anal gland.

24. Abscess
Rectal
lumen
Internal sphincter
External sphincter
Inter-sphincteric
abscess &
Routes of spread

25. Peri-anal Abscess and Fistula contd.
Fistula-in-ano ( anal fistula ) usually consists of
:
- internal opening
- primary tract
- external opening
Primary tract connects the internal and
external openings.

26. Intersphincteric fistula
Transsphincteric fistula
puborectalis
External
sphincter
Internal sphincter Fistula tract
Fistula tract

27. Suprasphincteric fistula
Extrasphincteric fistula
Levator
ani
Fistula tract

28. Peri-anal Abscess and Fistula contd.
Symptoms :
acute abscess – pain, fever
fistula- in- ano – chronic purulent discharge
Management :
Acute abscess– surgical inicision and drainage (Hilton’s method)
cavity is dressed with gauze ( changing every
24 hours )
wound is left open for secondary healing

29. Peri-anal Abscess and Fistula contd.
• Anal fistula – treatment according to the type
of fistula
•
1. Incision( lay open the primary track )fistulotomy
•
2. Excision-fistulectomy
•
3. Seton
•
4. Anal Plug
•
5. Advancement flap
•
6. Kharsutra

30. Fistula tract
Fistulectomy:
step-I

31. Fistulectomy:
step-II

32. Fistulectomy:
step-III

33. Multiple Fistulae

34. Benign rectal tumors
The most frequent are polyps.
Polyp is a localised elevated lesion arising from an epithelial surface.
Polyp - adenoma : 90%
- other ( inflammatory, hyperplastic etc. ) : 10%
2 types of adenoma : tubular ( pedunculated ) 20%
villous ( sessile )
80%
Symptoms : bleeding, mucoid discharge ( villous )
Treatment : polypectomy by colonoscopy
surgical excision – large sessile polyp

36. Colonoscopic polypectomy

37. Colorectal Cancer

38. Epidemiology
– Most common internal cancer in Western Societies
– Second most common cancer death after lung
cancer
– Generally affect patients > 50 years (>90% of cases)

39. Colorectal Cancer
• Forms
– Hereditary
• Family history, younger age of onset, specific gene defects
• E.g. Familial adenomatous polyposis (FAP), hereditary
nonpolyposis colorectal cancer (HNPCC or Lynch
syndrome)
– Sporadic
• Absence of family history, older population, isolated
lesion
– Familial

40. Pathology
• Spreads circumferentially
• 6 months required to involve a quarter and 18 months to
2 years for complete encirclement.
• Histopathology
– Generally adenocarcinoma
– Squamous cell carcinoma in some cases of anal CA

41. Colorectal CA

42. Duke’s classification of rectal CA
• A- limited to rectal wall- excellent prognosis
• B- extended to the extrarectal tissues but no
mets to lymph nodes- reasonable prognosis
• C- secondary deposites in the regional lymph
nodes
C1- local pararectal lymph nodes only
C2- nodes along blood vessels also

43. Histological Grading
Low grade- well differentiated- 11% -good
prognosis
Average grade- 64%- fair prognosis
High grade- 25%- poor prognosis

44. Clinical Presentation
• Depends on location of cancer
• Locations
– ⅔ in descending colon and rectum
– ½ in sigmoid colon and rectum (i.e. within reach of
flexible sigmoidoscope)
• Caecal and right sided cancer
– Iron deficiency anaemia (most common)
– Distal ileum obstruction (late)
– Palpable mass (late)

45. Clinical Presentation
• Left sided colon and sigmoid carcinoma
– Change of bowel habit
• Alternating constipation + diarrhoea
• Tenesmus
• Thin stool
– PR bleeding, mucus

46. Clinical Presentation
• Rectal carcinoma
– PR bleeding, mucus
– Change of bowel habits
– Anal, perineal, sacral pain
• Constitutional symptoms
– Loss of appetite, loss of wt., malaise
• Bowel obstruction

47. Clinical Presentation
• Local invasion
• Anterior- prostate(male),vagina, uterus(female) bladder,
posterior- sacrum, sacral plexus, laterally- pararectal
tissue, ureter
• Metastasis
– Liver (hepatic pain, jaundice)
– Lung (cough)
– Bone (pain,leucoerythroblastic anaemia)
– Regional lymph nodes
– Peritoneum (Sister Marie Joseph nodule)
– Others

48. Examination
• Signs of primary cancer
– Abdominal tenderness and distension – large bowel
obstruction
– Intra-abdominal mass
– Digital rectal examination – most are in the lower
part of rectum and can be reached by examining
finger
– Sigmoidoscopy & biopsy
• Signs of metastasis and complications
– Signs of anaemia
– Hepatomegaly (mets)
– Bone pain

49. Investigations
• Faecal occult blood
– Guaiac test (Hemoccult) – based on pseudoperoxidase
activity of haematin
– Immunochemical test (HemeSelect, Hemolex) – based
on antibodies to human haemoglobins
– Used for screening and NOT for diagnosis

50. Investigations
• Colonoscopy & biopsy
– Can visualize lesions < 5mm
– Small polyps can be removed or at a later stage by
endoscopic mucosal resection
– Performed under sedation
lesion
colonoscope

51. Investigations
• Double contrast barium enema
– Cannot detect very small lesions
– All lesions need to be confirmed by colonoscopy
and biopsy
– Performed with sigmoidoscopy
– Second line in patients who failed / cannot
undergo colonoscopy

52. Other Investigations
• CT colonoscopy
• Endorectal ultrasound
• CT and MRI – staging prior to treatment
• Blood tests
- Complete blood count, Ur/Cr, LFT, coagulation profile
– Tumour marker CEA
• Useful for monitoring progress but not specific for
diagnosis

53. MANAGEMENT

54. principles
• Surgery is the treatment of choice whenever
possible
• In cases of locally advanced tumors pre-op
chemoradiotherapy may downstage the
tumor
• Palliative treatment in inoperable cases

55. Management
• Caecum or ascending colon
– Right hemicolectomy
– Vessels divided – ileocaecal and right colic
– Anastamosis between terminal ileum and transverse colon
• Transverse colon
– Close to hepatic flexure  right hemicolectomy
– Mid-transverse  extended right hemicolectomy (up to
descending) + omentum removed en-bloc with tumour
– Splenic flexure  subtotal colectomy (up to sigmoid)

56. Management
• Descending colon
– Left hemicolectomy
– Vessels divided – inferior mesenteric, left colic, sigmoid
• Sigmoid colon
– High anterior resection
– Vessels ligated – inferior mesenteric, left colic and sigmoid
– Anastomoses of mid-descending colon to upper rectum

57. Management
• Obstructing colon carcinoma
– Right and transverse colon – resection and primary anastomosis
– Left sided obstruction
• Hartmann’s procedure – proximal end colostomy (LIF) +
oversewing distal bowel + reversal in 4-6 months
• Primary anastamosis – subtotal colectomy (ileosigmoid or
ileorectal anastomosis)
• Intraoperative bowel prep with primary anastomosis (5%
bowel leak)
• Proximal diverting stoma then resection 2 weeks later
• Palliative stent

58. Resection

59. Rectal Cancer
• Options
– Low anterior resection
– Transanal local excision
– Abdomino-perineal resection
– Palliative procedure

60. Rectal Cancer
• Anterior resection
– Upper and mid rectum cacinoma
– Sigmoid and rectum resected
– Vessels divided – inferior mesenteric
and left colic
– Mesorectum resected
– Coloanal anastomosis
– High – intraperitoneal anastamosis
(upper 1/3 of rectum)
– Low – extra-peritoneal anastomosis
– Post-op recovery
• Increased stool frequency
• 12-18 month to acquire normal
bowel function
• 1~4% anastamotic leak

61. Rectal Cancer
• Abdominoperineal resection
– Larger T2 and T3 or poorly
differentiated tumour
– Rectum mobilised to pelvic floor
through abdominal incision
– Sigmoid end colostomy
– Separate perianal elliptical
incision to mobilise and deliver
anus and distal rectum
– Vessels ligated – inferior
mesenteric

62. Rectal Cancer
• Hartmann’s procedure
– Acute obstruction
– Palliative
• Transanal local exision
– Early stage
– Too low to allow restorative surgery
• En block resection – for locally advanced colorectal carcinoma
(remove adherent viscera and abdominal wall)

63. Palliative procedures
– Diverting stoma
– Radiotherapy
– Chemotherapy
– Local therapy – laser, electrocoagulation, cryosurgery
– Nerve block

64. Complications
• Liver metastasis
• Local invasion → perineal and pelvic pain
• Bowel obstruction
• Fistula to skin or bladder
• Rectal discharge and bleeding
• Hypoproteinaemia
• Poor appetite

65. Prognosis
• 5 yr survivals
– T1 = >90%, T2 = >80%. T3 = >50%
– LN involvement = 30~40%
– Distant mets = <5%

66. Hereditary Colorectal Cancer
• Familial adenomatous polyposis
– FAP account for <1% of all colorectal cancers
– Due to mutation of the adenomatous polyposis coli
(APC) gene
– Numerous adenomas appear as early as childhood
and virtually 100% have colorectal cancer by age 50 if
untreated

67. Hereditary Colorectal Cancer
• Hereditary non-polyposis colorectal cancer / Lynch
syndrome
– More common than FAP and account for ~1-5% of all
colonic adenocarcinomas
– Due to a mutation in one of the mismatch repair genes
– Earlier age onset of colorectal cancer and predominantly
involve the right colon
– HNPCC also increases the risk of
• Endometrial, ovarian, breast ca
• Stomach, small bowel, hepatobiliary ca
– Renal pelvis or ureter ca

68. THANK YOU