Dr. V.Thusyanthan
Consultant Gastroenterological Surgeon,
Teachin Hospital Jaffna
Good morning all of you welcome to the CPD webinar series organized by the society for health research and Innovation first I would like to introduce you with the housekeeping rules the webinar link will be available from 9:00 a.m. to 9:50 a.m. to you to join in no late attendees will be entertained
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You have very special questions you can email us on our email office 33@gmail.com and we have a exciting news for you all the education training and Research Unit of Ministry of Health has taken an initiative to provide you with an important certificate for these all CPD followers of accredited CPD programs so
A circle has been issued by Ministry of Health dated 9th of October 20 23 so according to that we are very happy to inform that all followers of tre Knowledge Academy uh will be received CPD certificates and you have to fill a link that is provided by the Ministry of
Health with your details on or before November 2023 uh 15th of November 2023 through the link and this link will be posted in our Zoom chat and also in our WhatsApp chat so today’s topic is painful perianal conditions a clinical important topic in surgery so let me introduce our guest
Speaker today he is Dr V tantan he’s currently acting as the consultant gastrological surgeon at the teaching Hospital jafna Dr vant then obtain mbbs and MD surgery from the colu University and mrcs England and he was a senior clinical fow in upper and lower GS surgery at Broomfield Hospital
UK over to you sir thank you very much for the kind introduction first of all I would like to thank the organizers for offering me this platform traditionally surgeons are interested with the care of the anus related conditions and problems arising from the surrounding tissues unfortunately we are interested with the
Dirtiest part of the trade of medicine and I hope all of you will agree with me however we do our duty with dedication so that we keep the backyard of patients tidy and healthy so our colleagues healing from other specialities can enjoy the Glamorous part of the trade of medicine
Today I would like to focus on painful peral conditions the outline of my talk will be evolving around the clinic painful peral conditions just to refresh your knowledge on the anatomy of anal Canal to name certain reflexes and specialities related to defecation and other soci reflexes of the
Anus discuss clinical management of very common pain painful peral conditions let’s move on a patient who is having very severe pain at the anus or in the surroundings will be readily coming to us and elaborating the nature of his problem but due to social stigma and other various
Reasons patients who are having bearable pain or mild moderate pain try to hide their symptoms or they may not be coming out with full picture of the clinical problem so it is our duty to maintain High index of supic and explore the symptomatology of the problem and offer
Treatment otherwise we may miss a crucial diagnosis and patient will go on suffering the manifestations of painful penal conditions are not confined to anal because these manifestations can be an end result of other various systemic diseases for example painful peran fissure may be the first and so presentation of a parthida or
Hypothyroidism so whenever we are dealing with conditions of painful peral diseases we should focus on whether we are having any leads to any other systemic diseases that’s why this topic gets this important to medical officers consultants and other clans who are dealing with other clinical or medical Arenas actually whenever somebody comes
With painful peral conditions we have the tendency that we’ll be focusing on the current problem only but there may be an underlying Sinister pathology like inflammatory B disease or foral malignan here in our country we do not have a systematic screening program for foral malignancies so it is our duty to expose the
Symtoms and find out actually whether patient is having painful P condition only or whether there are any Associated Sinister pathology like Po malignancies we offer multiple treatments for various other disease conditions which can end up with constipation and in return patient may come with anal fure painful external thrombos hemoroids Etc
So it is imperative that we should inform our patients and alert them look I’m going to prescribe you this medicine or I am going to offer you this treatment so you may end up with this problem so we patient will be alert and they will seek our medical attention immediately whenever they
Develop the symptoms related to these conditions anybody who had painful peral condition will readily admit how it worse or agonizing pain had been without treatment so whenever we detect these conditions early and offer prom treatment most of the time we’ll be able to ensure the restoration of the
Quality of life and early return to work so in a way in at this National economic crisis we may be able to contribute the country as well this is a simple line diagram of an Canal so the lower rectum eventually turns into anal Canal you can see the rectal wall converts
Itself into internal spinter and you can see the three components of the ex spinter superficial subcutaneous deep which is confluency ring of the pelvic flow I would like to draw your attention two sets of Venus plexuses mentioned here one is external hemoroid you can see at the bottom end of the
Image another set of Venus plexuses named as internal h oids can be seen at the top end of the anal Canal here you can see the very important line called DED Line This DED line is the demarcation point where the somatic nervous Supply is is sorry somatic n Supply is for the a
Of the inner Canal below the DED line which is highly sensitive actually the portion of the inner canel above the DED line is receiving viseral nervous Supply and relatively insensitive I would like to just tell about the names of the defecation and Associated reflexes actually it’s a complex
Mechanism it is coordinated by intrinsic defecation reflex parasympathetic defecation reflex and our voluntary control actually it is a conditions reflex mechanism where we have conditioned ourself to go ahead with the defecation whenever it is socially acceptable the next follow chart is showing you the steps of defecation
Reflex how it is initiated and how it is executed but I don’t want to go into each and every steps it is just for your knowledge you can always rer from the reading materials but I would like to draw your attention over a very specific thing that
Is the mucosa that is lining the lower rectum and the upper end of the inner is very specialized whenever the re are presented to that region for initiation of the defecation reflex the mucosa can analyze the nature of the content whether it is gaseous fluid or solid whenever it
Is convenient we can go ahead with rication otherwise we can selectively release gas without leaking any solid or liquid that’s why we are unable to replace this mechanism by any other means so far so whenever we are dealing with peral conditions we are very careful not to temper this aspect obviously painful peral
Conditions will be presenting with pain there’s no doubt actually good old clinical textbooks will be telling that diagnosis of peral conditions is made at the lobby of your surgery not exactly on the examination couch not only the pain the patients may come up with either lump at anus or
Ongoing P discharge through the anus or through the openings closer to the anal opening they may be having either fresh or altered bleeding they may have kisas the continuous ongoing urge to pass tools even after emptying there may be alteration in B habits at times patients present With Ur retention because we all
Know the U spins and anal spins share the same autonomic outflow at h234 level so due to referred pain any pain in the anal Canal or immediately after a surgery like homy an elderly patient specifically can go into Ur retention so in a patient who are coming with
Acute retention we should focus on whether patient is having any painful peral conditions as well if there’s an inflammatory or infective condition going on patient may present with also as far as assessment is concerned based on the clinical assessment we will be able to identify the most probable or possible
Diagnosis so we should obtain a detailed history the duration of the pain nature of the pain and Associate of symptoms I mentioned in the previous slide so that we’ll be able to AR the diagnosis we can simply confirm the diagnosis by visual inspection an external peral hematoma or fure are visible we always
Emphasize no examination is complete without D examination but painful peral conditions are an exception because patient is already in pain if he poke anything into the aners it will be aggravating the distress so it’s not edical or inh it’s inhuman to go ahead with digal examination so we tend to avoid that
Same applies for or troscopy also based on our clinical assessment we can decide on the investigations if there’s an inflammat condition we are suspecting for we can go for count CRP Etc or if there’s a constipation we can go for thyroid function test but at the accute stage these
Investigations may not help us at all later on we can offer certain Imaging modalities acute settings in acute settings we hardly use any imag modalities but if you’re not sure about any diagnosis we can go for endoscopic ultrasound scan to rule out any inpic abscesses or abscesses which
Are deep seated into the pelvic cavity which may present with pain over the Aus or perennial area mrf pelvis Also may help us in terms of assessing the fish to tracks and Associated absess collections for the reasons I mentioned above we tend to defer the endoscopic assessment
Also due to pain but sometimes we may have to go for an emergency endoscopic assessment as well the main objective of doing endoscopic assessment is to rule out any Associated pathology like poal malignancy inflammatory ball disease poal tuberculosis Etc if we think we have to examine the an
Canal immediately while the patient is having severe pain it is always better to go for examination and anesthesia examination and anesthesia will open room for us for proper assessment of the inal canal and furthermore we can offer treatments like in drainage or exploration of hist TR Etc
At the time itself so it’s it will help us in terms of treatment as well when somebody comes with painful peral conditions there are certain components of General care irrespective of the individual panal conditions patient is in pain so so it’s a must that we should offer adequate
Analysis we should objectiv assess the pain severity and according to the pain ladder we may offer pain relief failing to the patients sensitivity allergies Etc if you can ask from the patients who are having painful P conditions the DED experience they will tell you is trying to pass motion so
They will resist that Temptation and at the end they will become constipated and the visus cycle forms worsening the patient experience so it is imperative that we should give stool softeners or laxatives so the patient can pass motion with minimal efforts for patients with painful pain conditions or patients who have undergone extensive
Surgery we ex surgery in the peral area so we advise the patients to get a white mouth Basin or container so that they can sit comfort you ask them to fill that container with lukew water and dissolve at least half a kilo of salt table salt actually I’m
Referring to and then we expect them to sit there sit into the lukew water for at least half an hour this will reduce the tissue edema and in return reduce the pain and enhance the healing for an inflammat condition or infected condition we consider Mater as a
Treatment but there is an added value for Mater also even though it is not proven that it has got some soothing effect when a patient is in very severe pain now we are moving into individual conditions sorry I’m having some trouble in navigating so this image is showing accur thrombos external hemorrhoids you
Can see a BL like structure at the verge of the anus you can see the anal opening at the 3:00 portion of that BP this BP is the one that gives very a pain to the patient if we explore the history of the onset of this pain the
Patient will typically tell I was strugling and straining to pass motion all of a sudden I experienced very severe pain and I noticed this blp formed and now I am having agonizing throbing pain which is PR preventing me to do day-to-day activities this is the typical story we hear from
Patients this is what actually happens when a Venus plexus or vein in the external humorid ruptures and forms a seat if the patient is presenting within the 24 hours there’s always a place for Simo incision and squeezing out the blood clot under appropriate anesthesia
It may be local or it may be a regional one or general anesthesia but once he squee out the symptoms will subside to a great extent but if somebody is presenting late and when we examining this BP is not tensed and it is singing then we can
Give our general care with and tools of softness and reassure the patients saying look this is just a hematoma a blood clot that will be getting absorbed gradually so pain will be gradually Vanishing but we should warn them to avoid constipation to prevent similar s another painful pain condition is anal
Fisher when I was talking about anatomy of the in Canal I was telling you that below the DED line the anoderm is very sensitive it is supplied by the somatic nerve Supply when a patient is passing heart TOS there’s a tendency that there be here for linear laration
So patient will get acutely severe pain there are two types of fissures one is acute and cronic if the symptoms are persisting for the less than three months we usually call it as acute fissure the symptoms are persisting more than that we consider as chronic fissure
The next image is showing you the acute fissure the by the red arrow I have pointed out a longitudinal TI extending in to the inal canal starting from the inal W you can see some Slough also this is fish usually we see at see a Fisher at 6:00 position whenever the patient is
Lying on the Le position but in females we are seeing these fishes at 12:00 position as well however if someone is having Fisher in clock position other than the six and 12 we should suspect some sort of underlying pathology like inflammatory B disease tuberculosis the next image is showing a
Chronic fissure you can see the fissure with a skin tack we call it a sentinal tack whenever we are examining a patient if you see these TXS we will get to know immediately this patient had a long-standing anal Fisher so the management wise is a difficult condition to treat most of the time
We offer conservative management at acute stage not only the management plan I have given earlier as a general management care specifically for fish we can offer local applicate applications like topical applications containing either gtn or calcium General blockers those applications will relax the Sprinter muscles and improve the healing however for a
Refractory anal fure which is not amenable to these conservative managements we may have to go for certain other interventions one option is botum Toxin injection it has got some proven value we will provide appropriate anesthesia for the patient and examine the anal Canal sometime we scoop the
Base of the anal Fisher to enhance the healing of the anal Fisher then by the side of the inal Fisher and into the interp groove we inject botum toxin it relax the muscles and inhal the healing as a last resort actually in the surgery we divide
And release the part of the internal SP whenever we are offering invasive internal spoy we should alert the patients there’s a possibility the patient may end up with either flatus or feal incontinence anyhow if no conservative measures or minimally invasive treatment options are not working we may have to
Offer this surgery for the patient the next one is thrombos or strangulated internal hemoroids whenever I was showing you the image of the anal Canal I was showing a Venus comple plexus named as internal hemorrhoids these Venus plexes are aligned along the arterial supply of the lower rectum and they form
The anal cushions so these anal cushions can prolapse anyhow they are originating above the DED line so most of the time early stage hemorrhoids grade one first degree or second degree humorid are painless but present with lump and Fe fresh peer bleeding but once these prolapse hemorrhoids the thrombos and
Strangulated patient will be having severe pain patient can’t sit properly patient can’t concentrate on the activities so there are two School TOS of thoughts regarding the management traditionally or conventionally we try to offer them conservative man pain relief analgesics relatives and hyperon saline application to reduce the swelling and the SE SP Etc
But there’s a place for surgery as well but surgery should be carried out with extreme care reason is there will be extreme swelling and tissue edema and large lumps may be protruding through the canel over enthusiastically if he go and remove those lumps he may not be able to remove sorry leave
Behind adequate amount of inct anal mucosa so later on patient may end up with stenosis so whenever we are doing emergency surgery for homine especially for thrombos strangulated situations we should be extremely careful not to remove excess anoderm prevent hosis I just added this image this is
The proos opic view of the internal hemoroids it will appear as a reddish blue very like B whenever we are withdrawing the protoscope whenever we are going for a r and liation or sclerotherapy we will be focusing on this suction sus but this condition is not painful
Now we are moving to pan lapsis this is very common conditions we encounter in our day-to-day emergency surgical practices I have put this image to show you even though absess is readily visible they have marked with arrows there’s a reason once the patient is under anesthesia sometimes you may not be able
To locate the maximum tender Point even though in this image it is visible sometimes we may not be having a pointing sign in the skin so whenever we are examining whenever we are asking from the patient where they feel maximum pain it is imperative that we should Mark that point so that the
Person who is doing the examination and anesthesia can explore that area and drain any deep seated absis furthermore on the abscesses there’s a condition called hyr sub it’s a skin related condition it can also present with features of per absis in the peral area and accary area patients we are having ocine sweat
Glands which can get infected and give R to this condition so we should be able to differentiate from proper periapsis to hyr is separating ABS is not a single entity because depending on the locations of the absess management differs a superficial peral absess warrants simple adequate incision and drainage but
Sometimes we may see abscesses in the is rectal forer interp area or sub mucos absis high in the lower rectum or in the high in The inal Canal at times we come across with sual levit absis so we offer either drainage through the skin or through the anus if
It is easily accessible through the anal or rectal mucosa for an isure elapses worst case scenario is they may end up with whole shoe absess around theas so we may have to release the whole set to get good train so when it comes to P lapsis we should offer examination and anesthesia
Of the inor rectum and we should Place adequate inis and drainage promply then we can give a course of metol for one week to settle down the infection but once we have done the acute stage drainage patient may end up with a non-healing wound that will tell us
There’s a fistula fistula is an abnormal connection between two Serv you all know here it’s a skin and the anal Canal or re M if someone comes with this sort of image we should suspect p they may give a pass hisory of absess drainage or they may not give but is
Imperative that we should deal with this fistula as well because even though fistula per say may not be painful occasionally that external draining site may get obstructed so they may end up with absess again this is good source law if you assume the patient is lying
On the theom position if you draw an imaginary line between 3 and 9:00 position the fish openings Anor to the lining will be opening into the corresponding clock position but if it is a complex fista and if the external opening is mainly in the posterior or below the imaginary line
They always tend to open at 6:00 POS this is there are exceptions also but it is good to know about this law based on the internal opening site we can categorize fisha into low anal fisha and high anal fisha the low enal fisha are the ones
Which opens below the DED line here you can see the DED line The Superficial fisha can open below the ended line superficial Alish or low Fula can be laid open without minimal damage to the sorry with minimal damage to the SP but the situation may be complex the
Pish track can go between the in two spinter internal and external spinter and may have trans spinter component as some high fista can open into the right above the p flow when we are dealing with this fistula we should be careful if you go and release or lay
Open these tracks we may in damage the anal spinter and at the end patient may end up with anal incontinence so here at acute stage whenever there’s a cavity or collection we will go for draining seone once the inflammation and C settles down then we can convert the draining seone into cutting seone
So without minimal without major damage to the inner spinter we can get rid of the fista usually we offer as a stage procedure but there are Noel techniques we can seal with enal pl we can go for laser treatment but we should alert the patients these treatments are not completely full proof
There are chances patient may get recurrences now we are looking at the prolapse rectum to the anus rectal collapse per se is relatively pain free but when it is edable and strangulated patient will be coming with very severe pain and it’s a surgical Ames usually we will be able to reduce
The rectum without any sub but once it is strangulated it may be difficult so in the clinical scenario whenever we are receiving patients with this sort of complaint it is bit difficult Force to differentiate between the thrombos prolapsed hemorrhoid and strangulated rectal prolapse especially when the size is very
Similar if you look carefully the Rector prolapse will be having mucosal holes on circumferential Arrangement if you look at the prolapse thrombos hemoroids the riches will be longit placed and if he Pulpit gently without causing pain to the patient we can identify the full thick sorry full thickness of them
Coming this is how weate between the thros hemoroid from The Stang rectal prolapse management for a thrombos sorry for a strangulated rectal prolapse sometimes we may have to resuscitate the patient and take to theater and appropriate anesthesia we may have to go for a reection called alomia
Procedure at your level it is always better to know how to identify and differentiate so that you can direct the patient for appropriate care this image is showing peral you can see the anal Canal floating between the among the neon this condition also extremely painful we see more often in diabetic
Patients we may have to do extensive W de rment and we may have to achieve skin soft tissue cover and skin cover after ass the isue loss this is again another painful P condition proctitis is also present with pain but there are several causes for protis one is sexually transmitted diseases which can
Predispose to protis previous days radiotherapy for prostate cancer or cervical cancer can end up with protis along with peral bleeding inflammatory B dis obviously having some components of protis as per the involvement of the bowel segments but food related infections can also lead to non specific protis whenever we divert the vle
Streaming for various reasons let’s say we offer a diversion stoa defunction sto or an obstructive leion or for other for any other reasons for incon ETC patient may end up with diversion Poes or propes these conditions can also present with painful peral situations difficult condition we come
Across is proia fex it’s an idic condition if you explore the history of the patient they will be telling you that patient we get patient will be getting excruciating pain which lasts for seconds to several minutes it may go up to 90 minutes as well so they will feel very s pain
At disturbing their activities and they can’t concentrate on anything they can’t sleep but later on it completely vanishes without any intervention all other investigations assessment may show normal findings except for high anal tone but aor manometry will be professional for these conditions we usually offer supportive management along with reassurance saying
That this will not C any long long-term seqing for the patient so they can offer s paaths we can offer tropical applications containing gtn or calcium General blockers so that patient can get pain relief at the time whenever they pain we should not forget about the anal
Trauma a patients who had a fall from height or a spike injury can present with pain at the anus people insert various items into the rectum I have removed Coca-Cola bottles toiled brushes from the anus so we should suspect for insertion also patient may be having Associated psychiatric conditions also so we should
Focus on that aspect as a person who is having anal sex can also have a can have anal trauma and end up with painful anus not only that we undertake multiple surgical procedures around the enam sorry around the anus and the peral area so after the surgery patient may
Come with pain ongoing peral bleeding hematoma formation especially after scapy for a painless hemorrhoids or due to pain patient may avoid passing stools and coming with FAL infection such patients will be telling us they are having throbbing pain at the rectum and the anal canal and they are
Unable to pass any to satisfactory but few drops or some amount of liquid phases is leaking out without then we should suspect peal infection and we can can prescribe them the disinfection regime with alcox and clean anema Etc so that that will relieve their pain or patient may come with human
Retention we see this situation as I mentioned you earlier after a homy elderly people come with u retention so whenever somebody comes with Ur retention we should ensure that we should we should ensure that they are giving adequate anesis for the pain following hum homy so that they can pass urine without
Any there are certain conditions which are not directly related to Canal but can be perceived as pain in that area this is just the list Final lapsis oidia B absis and herp of the pinia I should tell you one story story once I got a
Call from GP in UK saying that there’s a young guy coming with very in a pain and they have found out he has put absess with threat tenderness swelling Etc so they have prescribed one antibiotic they have reviewed in 5 days time symptoms are worsening they have added upon the
Second antibiotics also but no response at now the redness is spreading into his strm as well I told him to send the patient across on examination I found it is herbis so we should be careful when we assessing these patients so that we can direct the patient appropriately for the appropriate care
So the take home message I would like to tell you all after after this draw Malik lesions can coexist with v pathology the presence of pain per se may not exclude the presence of malal leion so we should handle the situation appropriately with adequate analgesic and according to a working diagnosis
Based on our clinical assessment later on we should offer them endoscopic assessment to rule out any malic Les this a must even though patient is perfectly normal always do a digit examination once the treatment is completely successfully And you toer the patient or the patient for an IND here detailed clinical assessment itself will Point towards a possible pathology because when in accur setting if we focus on the symptom most of the time we can come diagnosis again the pain is a very severe one and we
Should offer appropriate care from Le so that we can ensure that good quality of life thank you thank you for your very informative lecture sir are you EXP expain all the details very clearly and very practical manner so we have one question what are the analgesics prescribed so that’s why I didn’t commit
Myself to analgesics because NS is are the best choice provided the patient is not having any peptic aler disease or anything or good sorry renal issues but we had to uh go along the pain ladder opioids whenever we are using for very severe pain we should be careful they can render
The patient constipated which can in return ver in the painful peral condition so we should be careful whenever we are prescribing analgesics so it’s a tailor made or individualized regime we can offer based on the patient preferences patients allergies and disease conditions and there’s one option we can
Offer ANL block if facilities are available but we should warn the patients that it’s an invasive things again patient may end up with abscesses due to infections we introduce whenever we are injecting analgesic materials so anal block is at one option but we should want the patient regarding the risk of developing
Absess anything else yes we have few more questions so sir these are the questions which participants have sent us in the pre- survey thank you thank you thank you I’ll go one by one I go through one by one so how we can prevent fistula formation yes fisha may be an idiopathic
Phenomenon or a presentation of an underlying pathology like tuberculosis malignancy or influent ball disease so if we identify an underlying cuse we should treat that c appropriately tuberculosis with antituberculosis medications inflammat B disease we should optimize the care of inflammat B disease and malignancy we have to deal with accordingly for an idopathic
Fistula which is presenting with Pepsis and which opens up into the inner Canal into the skin in both directions then the best way is to avoid constipation we often see patients who are having constipation end up with fistular formation do all peral pain need medical intervention that
Depends I have mentioned you about the proia fug which is an tic condition we do not have a definite management for that but we have to explain them we have to rule out other pathologies which can end up with painful PR condition if if do not find any other obvious cause
Then we can reassure the patient saying that this condition is not going to give you any long-term problem but conly you will be feeling extreme pain so we can offer pain relief or topical applications to get the pain relief whenever the patient experiences pain the fourth question is how to manage complex peran
Fistula whenever somebody comes with per complex peral fista we suspect an underlying problem so we do an endoscopic assessment to rule out any inflammat B disease or inflammation in the lower rectum or mment then we offer the patient the examination anesthesia we explore the tracks using either hydrogen peroxide or gentle prob
With lacrimal probes and we will teack all those tracks whenever possible with draining siton and we’ll take a sample of the track for histology histology itself may tell us the reason for the complex nature of this Pista for example we have diagnosed TB tuberculosis on the histology of the fular
Tra the fifth question is difficulty in differentiating external hemorrhoid from the skin text in OPD settings true if we dig into the history Tre with the patient they may tell us the history of pain suggest of anal fure so when we are examining or inspecting the peral
Area in our clinical setting we can see the tax and the depression in the canal which will be showing uh the past or healed is if it is external hemorrhoid most of the time it will be painful So based on the history itself we can differentiate ex hemoroid sometimes you can
Get keratinized and thrombos so it will be like a heart Mass the skin T will be a very slender thin structure can we identify retrospectively also if we can do digital examination without any pain for the patient we can feel the fast or healed fure at the sight of the skin
TCT that’s why we call it as Sentinal TCH what are the resolving conditions and the duration of observation what are the condition that need emergency good most of the painful P conditions require emergency treatment but whether we are going for surgical intervention or not is the question we are supposed to answer at
That point if it’s a peran lapsis we should offer them examination and anesthesia of the in rectum and drainage accordingly if it is a Fisher we can go for conservative management OB if it is presenting as the first presentation but if it’s a long-standing problem affecting the patient very much
And disturbing the quality of life of the patient then we can go we can discuss with the patient whether to go for an intervention which either like B toin injection or a lateral internal spom so that depends on the patients presentation s to the pain and the nature of the underlying pathology but
Most of the painful peral conditions warrants emergency treatment I will tell you peral pain in females when sitting down with all the scans and tests are negative surely I’m not uh sure about this peral pain in females sometimes may be related to their past episiotomies and so on or there may
Be other hyper sensitivity issues for females but as far as anal canal and perennial structures are concerned if we go for a proper assessment with clinical sorry clinical assessment with history and examination and if you do the relevant examination sry investigations and we if you P out any
Signif pathology we can go for reassurance and pain relief for the patients but it is the territory of gynecologists for them to look from their point of view whe they have got any other problems to sort out what is anal fistula anal fistula is an abnormal communication between the skin and the
Anal Canal the definition of pathological definition of Pista itself abnormal connection between two epithelial surfaces so here one surface is skin other one is anod or anal mucosa that’s why it’s called anal fistula if it is having only one opening we will call it as sinus here in anal fista we expect to
See two openings how to manage peral breeding in Primary Care settings this is based on how much patient has sorry how much blood patient has lost and how quickly the blood is passing and how hum stable the patient is sometimes you may not be able to manage
At the primary care settings so we have to transfer the patient to an appropriate care settings either to a hospital or somewhere but for your purposes if someone comes with extensive bleeding following a humorid surgery or fular exploration from the anal canal and if you think the bleeding is mainly
From the anal Canal all over there’s a trick you can get a 22 or 20 size French size polyad and then with lubricate the tip and enter and insert the cader into the lower rectum and inflate the balloon with 30 cc of distill water on noral S line and pull
The balloon or pull the C snugly to fit into the convergence of the lower rectum so that will compress the Venus plexuses and the vessels gently so per rectal beaing will stop temporarily so that will give you some time frame or time lapse so that you can transfer the patient for appropriate
Care this is a simple trick that can help us provided that leading is mainly from the inal canal or lower rectum but it will not work for bleeding from higher ups so we should direct the patients immediately for appropriate Care Management of rectal pullups in Primary Care the rectal
Pullups is something that is painless it becomes painful when only it gets strangulated for Rector prse with gentle pressure we can reduce the uh prolapse into the anal Canal into the pelvis the main reason for reor prolapse long-standing constipation so we can address the constipation with single or
Double laxative so that patient can pass tools without any efforts so the prods may not reappear but at the same time it is always better to get surgical opinion regarding the definitive yeah or reection or trans abdominal procedures to correct the lse however if somebody comes with strangulated prolapse rectum it’s a
Surgical emergency so I feel the primary care may not be appropriate to handle that patient the patient should be transferred to a surgical yeah management of painful lumps in perianal regions the painful lumps maybe due to various reasons so if it is infected and absess you can go for drainage
But there are other conditions like peral vs skin condition like hytiva so it is the must that we should be able to identify the exact nature of the problem so that we can deduct a patient to appropriate specialist for example if it is peran vs will be able to
Hand if it is hydr Suba we always get the help of our plastic colleagues so we will exercise and we will offer skin graft so that the wound will be healing quickly in such situations as surgeons we offer diversion sto to minimize the contamination of the skin Gras
Side so that wound will heal without any issues so it depends on the diagnosis we make so what about PR yes PR itself is an deting condition but as it is beyond the scope of this lecture so I didn’t touch it sometimes patients may be having hemorrhoids which may lead to provus Ani
There are several reasons over say it can be due to discharge from the anal condition parent discharge from the fista May due to pin worms so we should explore the possibilities and treat them accordingly sometimes we come across patients with Pro Z with obvious with no obvious cause so we
Try to manage them symptomatically internal hemorrhoids versus external hemorrhoids difference internal hemorrhoids are the hemorrhoids which are situated above the DED line forming the anal cions along the AR supply of the lower so we conventionally expect them to be there at 4:00 7:00 at 11:00 position of the anal
Canal provided the patient is on the otomy position the external hemorrhoids can occur at any clockwise region of the anus usually it occurs at the anal Verge not inside the anal Canal I have shown you in the anatomy of the an Canal these flexes are situated externally below the skin so
These flexes can rupture whenever somebody is staining a lot to pass motion so they present as thrombos exal hemorrhoids sometimes the internal hemorrhoids has PR for a long time and they get keratinized so we feel right it’s a humid Lum with K skin covering the humorid Lums that also we see for
Such situations we offer homy we will exercise the part of the cized portion of the internal hemorrhoids also leaving behind the appearance of floral it may be too complex for you all to understand while we are leaving behind the tissue Bridges intact tissue Bridges between the hemid Lums while we are exercising
So it will at the end of the surgery the an will appear as the wound will appear as a clo appearance so there we would have removed part of the kenized internal humanoids as well CRP level is normally increased in inflammatory bowel disease or itable B syndrome in irritable ball syndrome CRP
Will be normal in inflammat ball disease CRP will be elevated itable ball syndrome is something related to functional ball Disorder so there will be no inflammatory or infective process going on so patients will be having perfectly normal inflammatory markers I’m referring to irritable ball Sy but in inflammat ball disease there will be
Extensive inflammation going on and it may involve termal lium segments of coron depending on the pathology it may be Chon disase or alitis so people may present with various manifestations like peral absis peral fista peral Fisher or fish Ino or protis or pancolitis Etc in situation the will be elevated not in irritable
World syndrome how to approach every condition and as primary care doctor and when to refer to specialist how to manage the conditions as a house office when we are coming across a difficult situation either in a clinical scenario or either in then surgery we always tell ourselves always stick to your
Basics so in the primary care level as as a house officer we should get a good history analyze the symptoms and look for the underlying pathologies any look for any other Associated medical conditions any medications which can predispose this condition so if you do a proper clinical assessment and examination then we will
Be able to identify the condition then we can refer to appropriate uh specialist so for a Fisher in noo if the patient is minimally Disturbed pain is amenable at Primary Care level itself you can treat provided you are good with your diagnosis then later on you can advise the patient to see a
Specialist for an endoscopic assessment so that we can R out any other underlying pathologies so for house officer there will be always supervision so there will be seniors to help them so if you are not sure r go for help even for experts we do not
Stop at our level we always go for second opion we speak to our seniors our trainers and send the patient across so that they can assess independently and help the patient so there is no there should be no ego or problem whenever we are getting second opinion it’s always
For the betterment of the patient can anal malan F like this yes true this very even though there’s a general believe that malignancies are painless anal malignancies can present with pain that’s why initially at the very beginning I told you underlying malignancy so it’s always better go for a
Reassessment once the pain settles and do the appropriate investigations how to manage the pregnant women with painful P conditions it’s a very common scenario we come across once the fetus increase the intraabdominal and P pressure the patient will be coming with either fissure or prolapse hemorrhoids we try to manage them as
Much as conservatively without offering any surgery or interventions so six baths pain relief n lg6 and uh minimally invasive injections or band liation Etc if the bleeding is very sever enough but following delivery we will offer them the appropriate assessment with endoscopy and so on so that we can uh help
Them uh to prevent further progress of the disase is sorry I mean we try to defer any major invasive procedures during the pregnancy we’ll try to manage conservatively and following delivery we can offer the appropriate treatment so Six B the question is it’s already answered thank you we can use it it is
Helpful thank you very much sir thank you our sincer thanks to Dr vantan consultant gast surgeon teaching hospital jaff for his excellent lecture and the precious time thank you