Fissure In Ano
It is crack in the skin-lined part of Anal canal. It is usually seen in young or middle aged adults & common in both sexes. The Causes are mainly are Constipation with Injury to Anus during passage of large hard stools. Presenting Complaints are pain & or swelling in the form of skin tag at anal region. Bleeding either in drops or streaks of blood along with stools.
- Intake of High fibre diet, green leafy vegetables, fruits, salads will help in prevention.
- Stool softeners should be used to avoid constipation
- Application of Lubricant & Local Analgesics ointments, sitting in hot water gives relief from the symptoms.
If the above fails to give relief then surgery is required. The options are:
- Fissurectomy: Excising the fissure which usually results in healing
a) Open: Incision of the overlying anoderm & direct exposure of the sphincter (muscular part)
b) Closed: Fissurectomy with division of the sphincter with repair.
The surgery above can be easily done as day care surgery without the need for hospitalization and the patient will be discharged on the same day.
It is a sinus (A tract which opens at one end only) situated a short distance behind anus (at the position of tail bone) & generally contains hair. Other sites of occurrence: Finger web in barber, under arm, between the thighs, umbilicus.
Symptoms: Usually occurs in a young adult who develops a boil (with pus) at the base of tail bone, with accompanying pain, which may burst or is opened by Doctor. Discharge of pus then ceases but a reddish swelling (Induration) persists – boil reforms & cycle repeats.
On examination: there will be midline opening or multiple openings, usually with hair projecting from the opening.
The 1st step of treatment is Anti-inflammatory drugs, Antibiotics, Injections within the sinus.
If the patient does not respond to the above, surgical treatment would be required.
Surgical Treatment by Excision of the Sinus is the procedure of choice. The Tract is laid open with removal of all debris & hair followed by primary closure over a surgical drain.
Post operatively, the patient is advised to keep the wound clean, wash the wound daily and use a hair-dryer to keep the wound dry. To prevent hair entering into the wound, skin edges should be shaved weekly. Alternatively, laser treatment for the permanent removal of hair is also advised once the wound heals well.
Loss of elasticity of veins in the anal canal & lowermost part of rectum leads to development of Piles. It in seen in both the sexes, with chances increasing with age.
Piles are classified as:
- Internal piles (arising in the upper two-thirds of anal canal)
- External piles (skin covered lower one-third of the canal or at anal opening)
Internal piles occur due to obstruction in venous return.
Other causes are Hereditary, physiological factors, constipation, diarrhea, straining at stool, Inadequate fibre diet etc.
There are 4 grades as follow:
Grade 1: Painless Bleeding, Anal Discomfort.
Pile may protrude while straining but not prolapse
Grade 2: Painless Bleeding, Discharge, Itching.
Prolapse visible at straining but spontaneously returns to normal when straining ends.
Grade 3: Painless Bleeding, Discharge, Itching.
Prolapse has to be reduced manually.
Grade 4: Bleeding with pain, Discharge, Itching.
The piles always remain prolapsed.
The various options available are as follows:
- Injection Sclerotherapy: Injecting sclerosing agent in the pile mass.
- IRC (Infra-red coagulation)
Grade III or higher Piles would require surgical treatment. A newer option is
- MIPH (Minimal Invasive procedure for Haemorrhoides): It is newer modality available which shows lesser pain, minimal bleeding & shorter hospital stay with an early return to work.
Fistula In Ano
It is a track which connects the external opening on the peri anal skin to an area in the depth of the anal canal or rectum.
It mainly is caused due to anorectal abscess which bursts or is opened inadequately.
Clinical Presentation :
Repeated episodes of painful swelling near anal verge.
Sudden feeling of something bursting with pus discharge.
Bleeding mixed with yellow purulent discharge.
The only answer is Surgery.
The procedures are as follows:
- Fistulotomy: The fistula is incised from the external opening to the internal opening. The floor of the tract is scooped & wound heals by granulation.
- Fistulectomy: The entire tract is excised from external to internal opening.
- Sphincter saving Fistulectomy: The tract is cored from the external to the internal opening protecting the damage to the sphincter.
Appendix is a narrow blind tube like structure with its only open end communicating with the caecum (junction of small & large intestines). This blind tube may get occluded due to enlarged lymphoid tissues. Other causes of obstruction include, stool particle, tumours, parasites, low dietery roughage with high intestinal pressure which may cause functional obstruction.
Appendicitis can be divided into:
- Acute: a) Obstructive b) Non-obstructive
1) Acute Appendicitis is the most common abdominal surgical emergency.
The patient presents with pain which starts around the umbilicus & after few hours locates to right lower side of the Abdomen. This is usually accompanied with vomiting, fever and a loss of appetite.
2) Chronic Appendicitis: Recurrent attacks of Acute Appendicitis over several months.
Acute Appendicitis Treatment is as follows:
If there is no appendicular lump, then appendix should be removed.
If there is an appendicular lump: Immediate 1st line of treatment with IV Antibiotics followed by an interval appendicectomy.
a) If Appendicular lump fails to resolve, indicates that there is pus within it (Appendicular Abscess).
b) Perforation of Appendix is common if not removed in acute attack under favourable conditions.
Chronic Appendicitis Treatment: Well planned surgery
Gall stone is formation of stones in gall bladder.
Gall stones (Cholelithiasis) are divided into the following types:
a) Cholesterol stones
b) Pigment stones
- Infective: Mixed stones
- Metabolic: These result from derangement in metabolism either of cholesterol or of bile pigments.
- Infective: These are preceded by infection in the Gall bladder.
These are seen 2-3 times more commonly in women than men & the incidence increases with age, women taking contraceptive pills. Obesity & high calorie diet are predisposing factors.
8 to10% of patients do not show any symptoms (silent stones) & are diagnosed during a routine health check-up or during an operation.
Normally the patient would present with Pain in right upper side of abdomen with Acidity & Heartburn, occasional nausea & vomiting.
Discomfort in abdomen after fatty food is specifically seen in this condition.
Jaundice can be seen due to cholangitis or stone blocking the bile duct.
The Gall Bladder becomes inflamed & distended, causing abdominal pain & tenderness. The patient presents with sudden onset of pain in right upper part of abdomen, lasting several days instead of hours, severe nausea and vomiting. Abdominal pain may also radiate to the back between the shoulder blade.
- If Cholecystitis does not resolve it may progress to empyema ( Lumen gets filled with pus)
- Perforation: It is rare but when occurs results in
a) Generalised peritonitis.
b) Localised abscess
c) Fistula formation with common bile duct, duodenum, colon, stomach.
The 1st line of the treatment is as follows.
1) Bed rest & stopping oral feeds & Nasogastric tube aspiration
2) Intravenous fluids must be given as there will be no oral intake.
3) Antibiotics, Anagesics & Sedatives should be given & a close watch is kept to assess progress.
If the temperature does not come down & any complication occurs, then immediate surgery is mandatory.
Laparoscopic Cholecystectomy : Removal of Gall Bladder. This is the Gold Standard.
It a protrusion of a viscous or a part of a viscous through a normal or an abnormal opening in the wall if the cavity in which it lies.
The Commonest types are as follows:
- Congenital e.g. Indirect inguinal hernia.
a) Sudden powerful muscular strain resulting in tear of muscle fibres.
b) Conditions which raise the intra-abdominal pressure e.g: chronic cough, straining at motions in chronic constipation, straining at micturition.
c) Excessive fat deposition or excessive weight loss.
The only cure for a hernia is Surgery! All other conservative measures can only delay the inevitable. Currently, a Hernia can be operated either by Open Method or Laparoscopically.
In the Open Method, the surgery is usually performed under local anaesthesia and done as a day care procedure with the patient being allowed to return home the same evening.
Laparoscopic Repair of a hernia is most useful when the hernia is bilateral (both sides). It requires overnight admission at a hospital.