Small & Large Intestine

Surgical Procedures

Nancy Pérez
Ali Rizvi
Evelyn Vega
Si Kim
 Blind Loop Syndrome
Intestinal stasis and bacterial overgrowth related to
disruption of propulsive forces or other factors that limit
bacterial growth

Mechanism limiting bacterial population

• Peristalsis
• Gastric acidity SYMPTOMS AND SIGNS
• Steatorrhea
• Immunoglobulins
• Diarrhea
• Prevention of reflux of • Malnutrition
ileocecal valve
• Strictures, diverticula, fistulas
• Scleroderma
 Blind Loop Syndrome
Laboratory findings Imaging
• Megaloblastic anemia • Upper GI contrast
• Hypocalcemia radiographic study or CT
• Vit. B12 def. scan: May reveal blind
intestinal loop, intestinal
• Quantitative culture of
stricture, or fistula
upper intestinal aspirates
(> 105/mL are abnormal)
• 14C-d-xylose breath test

TREATMENT AND MANAGEMENT

• Surgical treatment of underlying fistula, diverticula, or other lesion
• Broad-spectrum
Blind Loop Syndrome
 Short Bowel Syndrome
Essential Features
• Extensive small bowel resection
• Diarrhea
• Steatorrhea
• Malnutrition

Significance
• May develop after extensive resection of the small
intestine
• When 2m-3m, serious nutritional abnormalities develop
• 1 m or less of normal bowel require parenteral nutrition
at home indefinitely
Short Bowel Syndrome
 Short Bowel Syndrome
Signs
• Diarrhea (> 2 L of daily fluid and electrolyte losses)
• Hemoconcentration
• Metabolic acidosis
• Hypokalemia
• Hypocalcemia

Imaging Findings
• GI contrast radiographic studies: Show decreased
intestinal length and decreased transit time
 Short Bowel Syndrome
Treatment
• Stage I: Intravenous feeding
o 1-3 months npo
• Stage II: Intravenous and oral feeding
o Diarrhea should be less than 2.5 liters/day for the oral feeding to
start, rehydration fluids
• Stage III: Complete oral feeding
o Adaptation from month to years
• If not tolerated parenteral nutrition

Medications
• Vitamin B12
• H2 blockers
• Antidiarrheal agents
• Supplemental electrolytes as indicated
Obstruction of Small Intestine
Mechanical obstruction physical barrier complete or partial

Simple occlusion lumen

Strangulated impairs blood supply leads to necrosis

Paralytic Ileus: neurogenic failure of peristalsis but nor

mechanical
Obstruction of Small Intestine
• Essential diagnosis
o Complete proximal obstruction:
• Vomiting
• Abdominal Discomfort
• Abnormal oral contrast x-rays or CT-scan

o Complete mild or distal obstruction:

• Colicky abdominal pain
• Vomiting
• Abdominal distention
• Constipation and Obstipation
• Dilated small bowel on x-ray
• Transition point on CT-scan
 Etiologies

Adhesion Neoplasm Hernias

 Etiologies

Intussusceptio Volvulus Foreign

n Bodies
 Etiologies

Gallstones IBD Strictures

Ileus
 Strangulation Obstruction
o Obstruction with compromised blood flow that can
progress to infarction or gangrene
o Venous obstruction occurs first, followed by arterial
occlusion, resulting in rapid ischemia of the bowel wall
Caused by
o Inguinal Hernia
• Weakness in abdominal wall
o Meckel’s Diverticulum
• Congenital diverticulum
• Located in distal ileum
• Remnant of yolk sac
o Volvulus
• Twisting of bowel
 Obstruction
Imaging Findings
• Abdominal x-ray
o Dilated bowel
o Air-fluid levels (minimal in early, proximal, or closed loop obstruction)
o The colon is devoid of gas
o Intraperitoneal air indicates perforation
• Contrast upper GI series: Assesses completeness of
obstruction
• CT scan
o Intraperitoneal free fluid
o Dilated bowel proximal and decompressed distal to the obstruction
o Gas
o Intraperitoneal free air or air-fluid levels indicate perforation
Obstruction
 Obstruction
Treatment
• Partial obstruction can be treated expectantly as long as there is
continued passage of stool and flatus; successful in 90% of such patients
• NG decompression

Surgery Different surgical procedures depending on the cause

Preparation
Nasogastric suction
o Relieves vomiting, avoid aspiration and dec. swallowed air
Fluid and Electrolyte resuscitation
o Isotonic saline solution, check urine output level, potassium levels
 Meckel’s Diverticulum
• True diverticulum
• Persistence of vitelline duct
or yolk stalk
• 2 inch long
• 2 feet from ileocecal valve
• 2% of population
• First 2 years of life
• Painless bleeding, volvulus
obstruction
• Resection is performed
Regional enteritis
Essential Features
• Diarrhea w/o blood
• Abdominal pain and
palpable mass
• Low-grade fever, lassitude,
weight loss
• Anemia
• Findings- thickened
stenotic bowel with
ulceration & internal fistulas
• Anorectal lesions
 Regional enteritis
Imaging Findings
• Upper GI contrast radiography
–Thickened bowel wall with stricture
–Longitudinal ulceration
–Deep transverse fissures and
cobblestone formation
–Fistulas and abscesses may also be
detected
• GI endoscopy
–Mucosal lesions
Skip areas appear normal
–Cobblestone appearance to the
luminal surface
–Stricture formation
 Regional enteritis
Extraintestinal manifestations
–Hepatobiliary disease
–Uveitis
–Arthritis
–Ankylosing spondylitis
–Aphthous ulcers
–Erythema nodosum
–Amyloidosis
–Thromboembolism
–Vascular disorders
–Cutaneous ulcers with a granulomatous reaction
Treatment
Medications
• Steroids, Aminosalicylates, Immunosuppressives, and
metronidazole (perianal disease)
• Infliximab
 Strictureplasty
Surgery
• About 70% of patients
with Crohn disease
undergo a definitive
operation
• If multiple strictures are
encountered, they can be
treated by “strictureplasty,”
in which the bowel is
incised through the stricture
and the wall is sutured or
stapled so that the lumen is
widened.
 Small Intestine Fistulas
Etiology: External fistulas may form spontaneously, but 95% complications of surgery

Essential Diagnosis Significance

o Fever and Sepsis o May form spontaneously as a
o Abdominal pain result of disease (Crohn
o Localized abdominal disease), but > 95% are
tenderness surgical complications
o External drainage of small o A high-output fistula produces
bowel contents > 500 mL/24 h
o Dehydration and o Intestinal fluid escaping
malnutrition through the fistula excoriate
the skin
o Fluid and electrolyte losses
o 30% of fistulas close
spontaneously
 Small Intestine Fistulas
Imaging Findings
• Fistulogram
o Location, number of
fistulas, length & course
of fistula tracts,
associated abscess
cavities, and the
presence of distal
obstruction
• Fluid should be collected
from fistula for
measurement of volume &
electrolyte composition
 Small Intestine Fistulas
Treatment & Management
First
o Fluid, electrolyte, and nutritional replacement
o Protection of skin from excoriation
o Abscess drainage
o No enteral intake and NG suction
o Control of sepsis
Second
o Delineate anatomy of fistulas by radiographic studies
Third
o Maintain caloric intake
o Drained abscess as they appear
Fourth
o Surgery
 Small Intestine Fistulas
Surgery
• The fistulous segment should be resected, associated
obstruction relieved, and continuity reestablished by
end-to-end anastomosis
 Acute Vascular Lesions
Intestinal Ischemia
A. Acute mesenteric vascular occlusion
B. Nonocclusive (hypoperfusion)

Occlusive
Essential of Diagnosis
o Severe diffuse abdominal pain
o Gross or occult intestinal bleeding
Etiology
o Mesenteric arterial emboli 50%
o Thrombosis of mesenteric artery 25%
o Thrombosis of mesenteric veins 5%
 Acute Vascular Lesions
Diagnosis
o Mesenteric arteriography
Differential Diagnosis
o Acute pancreatitis and
obstruction
Treatment
o First 12 hours are crucial
o Give Papaverine before
and after surgery
o Resection of the effected
area
o Massive volume support,
antibiotics and
anticoagulants
 Acute Vascular Lesions
Nonocclusive
o Accounts for 25% patients Diagnosis
with Intestinal Ischemia o Clinical picture same as
occlusive
Etiology
o Cardiacdystryhmia
o Sepsis Treatment
o Splanchnic o Vasodilators
vasoconstriction o Papaverine
o Resection surgery
Ischemia low perfusion in
antimesenteric border
 Gas Cysts (Pneumatosis
Cystoides Intestinalis)
• Gas filled cyst in the wall of • Fulminant pneumatosis,
the gut and mesenteric bacteria infection plus
• Primary- 15% Idiopathic necrosis bowel wall
• Secondary-85% Subserosal Treatment
o IBD o Oxygen
o Steroid therapy o Dietary manipulation
o Obstruction o Antibiotics
o AIDS
o Lymphoma
o Pulmonary
 Tumors of Small Intestine
Significance: Neoplasm of small intestine represent 1-5 %; 10% of small bowel tumors
are symptomatic; Lymphoma most common primary malignant tumor

Benign Tumor Malignant Tumors

• Polyps • Adenocarcinoma
• Hamartomas • Primary small intestine
• Peutz-Jeghers lymphomas
syndrome • Proximal jejunum in
• Familial adenomatous celiac disease
polyposis • Involved with B cell
• Juvenile Polyps • Immunoproliferative
small intestinal disease
 Carcinoid Tumors & Syndrome
Tumor of neuroendocrine cells
Significance Diagnosis
o 50 % of Small Bowel Tumors Dense core bodies on EM
o Produce 5-HT Elevated urine 5-HT
Symptoms
o Wheezing, right-side heart Treatment
murmurs, diarrhea, flushing Octreotide- suppress tumor,
relieves symptoms
✓ If tumor confined to GI no
carcinoid syndrome should be
observed
✓ If tumor metastasized outside GI,
carcinoid syndrome will appear
Large Intestine
 Obstruction of the Large Intestine
• Essentials of Diagnosis
o Constipation or Obstipation
o Abdominal distention and sometime
tenderness
o High Pitched Bowel sounds
o Abdominal pain
o Nausea and Vomiting (late)
o Characteristic x-ray findings
 Obstruction of the Large
Intestine
• Obstruction may be in
any portion of the colon
but most commonly is in
the sigmoid.
• Ileocecal valve
competent vs.
incompetent.
o Cecum 10-12 cm ↑risk of
perforation.
 Obstruction of the Large
Intestine
• Complete colonic
obstruction is most
often due to:
o Carcinoma
o Volvulus
o Diverticular disease
o Inflammatory disorders
o Benign tumors
 Small vs. Large bowel obstruction
Feature Small bowel Large bowel
Symptoms Abdominal cramps and Abdominal cramps and
vomiting at regular and vomiting less prominent or
frequent intervals frequent

Signs Mild to moderate abdominal Moderate to marked abdominal

distention distention

Bowel diameter (cm) >3 and <5 >5

Position of loops Central Peripheral
Number of loops Many Few
Fluid levels Many, short Few, long
(on erect film)

Bowel markings Valvaulae (all the way across) Haustra (partially across)

Large bowel gas No Yes

 Paralytic Ileus
• Result of peritonitis or
trauma to the back or
pelvis.
o Silent abdomen
o Tenderness
o Abdominal cramps
not present
o Films show dilated
colon
 Pseudo-Obstruction
• Massive colonic distention • On X-rays the abdomen
on the absence of a shows marked gaseous
mechanically obstructing distention of colon
lesion. o Usually localized to the right colon
• Seen in bedridden patients o Cutoff at the hepatic or splenic
who have serious flexure.
o Contrast enema proves the absence
extraintestinal illness or
of obstruction
trauma
• Abdominal distention
without pain or tenderness
is the earliest symptoms, but
then later can mimic those
of true obstruction.
 Imaging studies
• Plain radiography:
o Initial imaging study of choice
o Defines approx. level of
obstruction and may show
the likely cause

• Contrast enema or CT Scan:

o Confirms diagnosis of LBO
and help identify the exact
location
 Treatment of LBO
• Resection of all necrotic • Obstructing lesions in the
bowel and right colon:
decompression of the o If pt is in optimal condition:
• Resected in one stage with
obstructed segment. the ileotransverse colostomy
• Removal of the o If pt in bad condition:
obstructing lesion • Bowel resected no
anastomosis, ileostomy
• Colonoscopic balloon established in one operation
and in the second the
dilation with endoluminal anastomosis is done.
sent placement across
• Obstruction lesions in the
the obstructing area.
left colon:
o Resection, anastomosis may be
postponed and a temporary end
colostomy created (two stage
procedure)
 Cancer of the Large Intestine
Essentials of Diagnosis:

Right Left
Colon: Colon:
• Unexpla • Change
ined in bowel
weaknes habits
 Cancer of the Large Intestine
Essentials of Diagnosis:

Rectum
• Rectal
bleeding
• Change
in bowel
 Mechanism of spread for
Colon Cancer
A. Direct Extension B. Hematogenous
o Carcinoma grows
circumferentially and may
Metastasis:
completely encircle bowel o Lymphovascular invasion can lead
before its diagnosed. to hepatic metastases via the
portal venous system
o 1 year to encircle ¾ of the
bowel. o Tumors can also spread via the
o Longitudinal submucosal lumbar and vertebral veins to the
extension is due to invasion of lungs and other places
the intramural lymphatic
network o Rectal cancer via hypogastric
veins
o As lesions extend radially it
penerates the outer layers of
the bowel wall and it may
extend into neighboring
structures
 Mechanism of spread for Colon Cancer
C. Regional Lymph Node Metastasis D. Transperitoneal Metastasis
o Seeding-when tumor
o Most common form of spread extended through serosa and
o Longitudinal spread via tumor cells enter the
peritoneal cavity which
extramural lymphatics produce local implants or
o Rectal cancer metastasizes generalized abdominal
carcinoma.
proximally to the mesorectal,
iliac and inferior mesenteric E. Intraluminal Metastasis:
— Malignant cells shed from the
lymph nodes surface of the tumor can be
swept along the fecal current
and implantation distally on
intact mucosa occurs.
(rarely)
 Signs and Symptoms
• Adenocarcinoma of the
colon and rectum
doubling time of 130
days:
o Suggesting at least 5 -10 years
of silent growth are required
before a cancer reaches
symptom-producing size

• The average delay

between onset of
symptoms and definitive
therapy is 7-9 months
 Signs and Symptoms
• Right Colon: • Left Colon
o Larger caliber, thin o Smaller lumen, tumor can
distensible wall and fecal gradually occlude the
content is fluid these lumen causing:
causes the carcinoma to • Changes in bowel
attain large size before habits with alternating
constipation and
being diagnosed
increased frequency of
o Fatigue weakness due to defecation
anemia • Rectum:
o Hematochezia usually
persistent
 Imaging studies
• Barium Enema Contrast: • Colonscopy
o Carcinoma of left colon appears as a o Should be done on every
fixed filling defect with an annular patient suspected or known of
“apple core” configuration cancer
o Right colon appears as a constriction or o Allows for tissue diagnosis,
intraluminal mass evaluation for lesions and
opportunity for inkspot tattoo
marking for tumor localization

• Proctosigmoidscopy:
o 50-65% of colorectal cancers
are with reach.
o The cancer is raised, red,
centrally ulcerated and may
bleed
 Treatment
• Cancer of the colon:
o Wide surgical
resection of the
lesion and regional
lymphatic drainage
o Abdominal
exploration to
determine
resectability of tumor
and to search for
distant mestastases
 Treatment
Cancer of Rectum
o Treatment depends on location of the lesion, extent of
the tumor invasion, histopathological features and
patients condition.
o 6 principal procedures:
1. Low anterior resection of rectum
2. Abdominoperineal resection of the rectum
3. Laparoscopic assisted resection of the colon or
rectum
4. Local excision
5. Palliative procedures
6. Radiation therapy
Low anterior resection of rectum
Abdominoperineal resection of the rectum
Laparoscopic assisted resection of the colon or rectum
 Polyps
• Morphology: sessile (flat) vs
pedunculated (on a stalk)
• Mostly in rectosigmoid
Types:
a. Inflammatory
(pseudopolyp): benign
lymphoid polyp
b. Hyperplastic: most
common benign polyp
c. Neoplastic: tubular
adenoma (most common),
villous adenoma (highest
rate of malignant
conversion), tubulovillous
adenoma
d. Hamartomatous: juvenile,
Peutz-Jeghers
 Polyps cont.
S+S:
a. Asymptomatic (most common)
b. Melena
c. Hematochezia
d. Mucus
• Diagnosis: colonoscopy (best), barium enema and
sigmoidoscopy (less sensitive for small polyps)
• Treatment: endoscopic resection (snared) if polyps;
large sessile villous adenomas should be removed
with bowel resection and lymph node resection
 Polyposis Syndromes
Familial Polyposis = FAP • Hundreds of adenomatous
polyps within the rectum and
(Familial adenomatous colon that begin developing at
polyposis) puberty; all undiagnosed;
untreated patients develop
cancer by ages 40 to 50
• Autosomal dominant
• APC (adenomatous polyposis
coli) gene
• Treatment:
- Total proctocolectomy and
ileostomy
- Total colectomy and rectal
mucosal removal (mucosal
proctectomy) and ileoanal
anastomosis
 Polyposis Syndromes cont.
Gardner’s syndrome Turcot’s syndrome
• Sebaceous cysts, • FAP + malignant CNS
osteomas, desmoid tumor (glioblastoma
tumors multiforme,
• Extraintestinal tumors: medulloblastoma)
hepatoblastoma, • May be a/w HNPCC
papillary thyroid (Hereditary
carcinoma, nonpolyposis colorectal
periampullary adenoma cancer)
• Total colectomy • Total colectomy
 Diverticular Disease
Diverticulosis
• Multiple false diverticula
• 80% asymptomatic
• Massive, painless lower GI
bleeding is “classic”
• Colonoscopy (just
bleeding) or abdominal/
pelvic CT scan (pain w/
signs of inflammation)
• High-fiber diet, stool
softners
 Diverticular Disease cont.
Diverticulitis
• Acute abdominal pain
• LLQ tenderness and mass
• Fever, leukocytosis
• CT scan (best), X-ray
• Treatment:
- Initial: IV fluids, NPO, broad-
spectrum
antibiotics with anaerobic
coverage, NG suction (as
needed for emesis/ileus)
- Elective resection if recurrent
diverticulits
- Hartmann’s procedure in
emergency
• All patients must undergo a full
colonoscopy 4 – 6 weeks after
the attack to rule out
malignancy
 Colovesical Fistula
• Most common fistula b/w
the urinary bladder and
the GI tract
• MCC: diverticulitis
• Asymptomatic
• Fecaluria, pneumaturia,
refractory UTI
• Barium enema,
sonography, cystography
• Surgery if persist (fistula
closes spontaneously in
50% of patients w/
diverticulitis)
 Lower GI Bleeding
• GI bleeding distal to the ligament of Treitz
• Lower GI bleeding is considered massive when the patient requires 3 or more
units of blood within 24 hours
• Most common causes are diverticulosis and angiodysplasia. Other causes
include cancer, IBD, ischemic colitis, hemorrhoids
• Anticoagulation treatment increases the risk for lower GI bleeding
Treatment:
- Resuscitation
- If site identified but bleeding massive or refractory  segmental colectomy
- Without identification of bleeding site and persistent bleeding in an unstable
patient, an exploratory laparotomy is performed with possible total
abdominal colectomy with ileostomy
• Ileostomy: surgical creation of an opening into the ileum, with a stoma on the
abdominal wall.
 Volvulus
• Rotation of a segment of intestine
about its mesenteric axis
• Sigmoid colon (75% of cases) or
cecum (25%)
• More than 50% of cases occur in
patients over 65
• S+S: Abdominal distention,
cramping abdominal pain,
nausea, vomiting, obstipation,
and high-pitched bowel sounds
Diagnosis:
o Abdominal x-ray: Markedly
dilated sigmoid colon or
cecum with a “kidney bean”
or coffee bean
o Gastrografin enema:
Characteristic “bird’s beak”
at areas of colonic narrowing
 Pseudomembranous colitis
• An acute colitis characterized by formation of an “adherent inflammatory
exudate” (= pseudomembrane) overlying the site of mucosal injury.
o Most commonly due to overgrowth of Clostridium difficile [a gram-
positive, anaerobic, spore-forming bacillus]
• Typically occurs after broad-spectrum antibiotics (especially clindamycin,
ampicillin, or cephalosporins) eradicate the normal intestinal flora
S+S: Vary from a self-limited diarrhea illness to invasive colitis with megacolon or
perforation as possible complications

Diagnosis: Detection of C. difficile toxin in stool; proctoscopy or colonoscopy if

diagnosis uncertain
• Treatment: Stop offending antibiotic; give metronidazole or vancomycin PO
(if patient unable to take PO, give metronidazole IV)
• Prognosis: High rate of recurrence (20%) despite high response rate to
treatment
 Crohn’s Disease (CD) Ulcerative Colitis (UC)
Possible etiology Infectious Autoimmune
Location Any portion of GI (terminal Colitis = colonic inflammation;
ileum, colon); skip lesions, continuous lesions, always w/
rectal sparing rectal involvement

Gross morphology Transmural inflammation; Mucosal, submucosal

cobblestone-like mucosa, inflammation only; friable
creeping fat, bowel wall mucosal pseudopolyps w/
thickening (“string sign” on freely hanging mesentery
barium swallow), linear ulcers,
fissures, fistulas
Microscopic morphology Noncaseating granulomas, Crypt abscesses, ulcers,
lymphoid aggregates bleeding, no granulomas
Complications Strictures, perianal disease, Severe stenosis, toxic
malabsorption, nutritional megacolon, colorectal
depletion carcinoma
Extraintestinal manifestations Migratory polyarthritis, Pyoderma gangrenosum,
erythema nodosum, ankylosing primary sclerosing cholangitis
spondylitis, uveitis,
immunologic disorders
 CD & UC cont.
Treatment: Surgical
a. Crohn’s Disease (CD):
Strictureplasty and segmental resections because
recurrence is the rule and the goal is to preserve as much
healthy intestine as possible

b. Ulcerative Colitis (UC):

o Procedure: Proctocolectomy (curative)
o If patient is acutely ill & unstable due to perforation,
diverting loop colostomy is indicated.
Preop. Colon Surgery “Bowel Prep”
Eliminate fecal mass and reduce the numbers of
bacteria prior to operation
• Bowel prep:
1. Lower bacterial count in colon by catharsis
(GoLYTELY or Fleets)
2. PO antibiotics (neomycin, erythromycin)
preoperatively
3. Preoperative IV antibiotic with spectrum versus
anaerobes (e.g., Cefoxitin)
 Hemorrhoids
Prolapse of the submucosal veins Treatment: most treated w/ simple changes to
located in the left lateral, right anterior, diet , most do not require surgery or other
and right posterior quadrants of the treatment unless hemorrhoids are very large
anal canal and painful.
• Classified by type of epithelium: Nonsurgical: fixative procedures (rubber
Internal if covered by columnar band ligation or coagulation therapy)
mucosa (above dentate line), Surgical removal of hemorrhoids:
external if covered by anoderm hemorrhoidectomy
(below dentate line), and mixed if Combination of both most effective
both types of epithelia are involved
• Incidence: Male = Female
• Risk factors: Constipation,
pregnancy, increased pelvic
pressure (ascites, tumors), portal HT
• Diagnosis: Clinical history, physical
exam, visualize with anoscope
 Anal Fissure & Ulcer
Fissure: Split in the anoderm
Ulcer: Chronic fissure

• Located in midline, distal to

dentate line
• Sentinel pile
• Most commonly located
posteriorly (90%)
• Caused by forceful dilatation
of anal canal, usually from
defecation, leading to sphincter
spasm and local anoderm
ischemia
 Anal Fissures & Ulcer
Signs & Symptoms Diagnosis
o Pain and bleeding with o Physical exam reveals
defecation disruption of anoderm in the
o Pain may be tearing or midline at the
burning, worst during mucocutaneous junction
defecation, may last for hours
o Sentinel skin tag or pile may
o Blood may be noted on tissue
be present at the inferior
or on stool but not mixed in
margin
o Constipation may develop
secondary to fear of recurrent o Digital exam may reveal
pain sphincter spasm
 Treatment
• 0.2% nitroglycerin Surgery
ointment
Lateral internal anal sphincterotomy
• Botulinum toxin
infiltration into internal
sphincters may aid
healing
• Stool softeners
• Bulking agents
• Sitz baths
 Anorectal Abscess & Fistula
Result from occlusion of anal
glands and crypts at the
dentate line
o Occlusion may follow
impaction of vegetable
matter or edema from
trauma
o Fistula-in-ano from the anus
to the perianal skin
develops when abscess
cavity maintains persistent
communication with the
crypt
 Anorectal Abscess & Fistula
Signs & Symptoms
• Severe anal/perianal pain,
• Swelling and discharge
• Patients may have fever, urinary retention
• Sepsis may develop
• Bloody discharge

Exam findings- tender perianal or rectal mass

• Fistula: Internal and external openings with mucopurulent
drainage
• Transrectal ultrasound
 Anorectal Abscess & Fistula
Treatment for Abscess
• Treatment for abscess is
surgical drainage
• Catheter drainage prefer
over skin excision
 Treatment for Fistula
Salmon Goodsall Rule
• Identify direction of tract
• If sphincter muscle is not
involve simple incision of
the tract with ablation of
gland and saucerization
of the skin
• If muscle is involved use
collagen fistula plug
• If above failed, then
mucosal advancement
flap
• Seton
Endorectal Advancement Flap
Seton
 Tumor of the Anal Margin
Squamous cell carcinoma Basal cell carcinoma
• Mass bleeding pain, • Bleeding, itching, pain
discharge, itching • Superficial mobile lesions
• Lesions large centrally have raised irregular
ulcerated with rolled edges & central
everted edges
ulceration

Treatment
Treatment
• Small lesion <4cm local
incision • Same
• Deep lesion involving
sphincter require
abdominalperineal
resection
Abdominalperineal resection
Thank you for your attention