上海交通大學醫(yī)學院外科學各論（英文）課件第九章 結(jié)直腸和肛門疾病

AnalDiseasesAnalDiseasesAnatomyLevatoranimuscleDeepexternalsphincterandPuborectalismuscleConjoinedlongitudinalmuscleSubcutaneousexternalsphincterAnorectalringAnatomyLevatoranimuscleDeep2ArterialsupplyoftherectumSuperiorrectalarteryMiddlerectalarteryInferiorrectalarteryArterialsupplyoftherectumS3VenousdrainageoftherectumInternalhemorrhoidalplexusExternalhemorrhoidalplexusVenousdrainageoftherectumI4ReservoirFunctionMechanicaladaptivecompliance,lateralangulationofthevalvesofHoustonPhysiologicalcontractilewavesmorefrequentandhigheramplitudeinrectumthansigmoidReservoirFunctionMechanical5SensoryComponentsNeuropathwaysSympathetic+parasympatheticpathwaystointernalsphincter(hypogastric)Somatictoexternalsphincter(pudendal)SensoryComponentsNeuropathwa6SphincterfactorsBasaltonePressurezoneanalcanal25–120mmHg rectum5–20mmHgContinuoustoneofint.andext.sphincterincreaseswithincreasedabdominalpressureSphincterfactorsBasaltone7MechanismofAnalContinenceStructuralconsiderationsAnorectalanglebetweenrectumandanalcanalFlapvalveangleoftheanteriorrectalmucosacausedbypuborectaliscausesocclusionInternalsphincterincontinuoustonicstatewithexternalsphincterengagedduringVasalvaMechanismofAnalContinenceSt8AnalFissureUlcerinthelowerportionoftheanalcanalAcute/chronicprimary/secondarySx:analpain,duringandafterBM’sAnalFissureUlcerinthelower9AnalFissureTriadeofanalfissureanalpapillahypertrophyfissureinanosentinelpileAnalFissureTriadeofanalfis10AcuteFissureTreatmentinspection,usuallyincreasedanaltonecanbeappreciatedonrectalexamiftoleratedcleansingmeasurestypicallyresolvein6weekswithoutsurgicalinterventionAcuteFissureTreatment11ChronicFissuresentineltag,ulcer,hypertrophiedanalpapillaFormbecauseofswelling,edema,andlowgradeinflammationmaygoontofibrosisExtendsfromthedentatelinetotheanalvergeChronicFissuresentineltag,u12ChronicFissureTeatmentnitroglycerinointment0.2%-0.4%BIDTopicaldiltiazem(50%resolutionat6weeks)BotulinumtoxinAinjection–42%recurrenceat42months–sideeffectsSurgery:lateralinternalsphincterotomyChronicFissureTeatment13LateralinternalsphincterotomyLateralinternalsphincterotom14SecondaryanalfissureCrohn’sdiseaseNon-midlineorabnormalappearingfissureshouldundergomarginbiopsyAvoidsurgeryinneutropenicpatients–treatwithperinealhygineandpainreliefSecondaryanalfissureCrohn’s15AnorectalAbscessAnorectalAbscess16AnorectalAbscessInfectioninoneoftheanalglandsMaybeasymptomaticorcauseseverethrobbingpainthatresemblesafissureAbscessshouldbedrainedwhendiagnosedAnorectalAbscessInfectionin17AnorectalAbscessSx:severepain(aggravatedbywalking,straining)SwollenmassmaybeappreciatedAnorectalAbscess18AnorectalAbscessTreatmentdrainage,avoidpacking,noabscesstypicallyCrohn’sdiseaseoralmetronidazoleorciprofloxacinseemstohaveamitigatingeffectAnorectalAbscessTreatment19FistulaChronicformofperianalabscessEvaluationwithanoscopy,endoanalultrasoundClassificationFistulaChronicformofperiana20FistulaintersphincterictranssphinctericsuprasphinctericextraspinctericFistulaintersphincterictranssp21Goodsall’sruleGoodsall’srule22FistulaTreatmentUnroofingthefistula,eliminatingtheinternalopening,andestablishingadequatedrainageOlderpatientsuselooselytiedsetonstoallowforadequatedrainageFistulaTreatment23AnalfistulotomyAnalfistulotomy24Thread-drawingThread-drawing25HemorrhoidsHemorrhoids26HemorrhoidsVaricesofhemorrhoidalplexusA-VcommunicationinanalmucosaVascularcushions–thicksubmucosawithbloodvessels,smoothmuscle,elasticandconnectivetissueHemorrhoidsVaricesofhemorrho27HemorrhoidClassificationExternalskintagsExternalhemorrhoids(belowthedentateline)InternalhemorrhoidsHemorrhoidClassificationExter28InternalhemorrhoidsBleedingProlapsePain–usuallyassociatedwithotheranaldiseaseInternalhemorrhoidsBleeding29InternalhemorrhoidsTreatmentBulkingagentsforfirstandseconddegreehemorrhoidsSclerotherapyInfraredPhotocoagulationBanding2–3ligationsat4to6weekHemorrhoidectomyStapledCircularHemorrhoidectomyforprolapsedhemorrhoidsInternalhemorrhoidsTreatment30ProcedureforprolapsedhemorrhoidsProcedureforprolapsedhemorr31CircumciseforhemorrhoidsCircumciseforhemorrhoids32NeoplasmsoftheAnalCanalSquamouscellcarcinomaBasaloidCarcinomaMucoepidermoidCarcinomasAdenocarcinomasNeoplasmsoftheAnalCanalSqu33ThankyouThankyou34AnalDiseasesAnalDiseasesAnatomyLevatoranimuscleDeepexternalsphincterandPuborectalismuscleConjoinedlongitudinalmuscleSubcutaneousexternalsphincterAnorectalringAnatomyLevatoranimuscleDeep36ArterialsupplyoftherectumSuperiorrectalarteryMiddlerectalarteryInferiorrectalarteryArterialsupplyoftherectumS37VenousdrainageoftherectumInternalhemorrhoidalplexusExternalhemorrhoidalplexusVenousdrainageoftherectumI38ReservoirFunctionMechanicaladaptivecompliance,lateralangulationofthevalvesofHoustonPhysiologicalcontractilewavesmorefrequentandhigheramplitudeinrectumthansigmoidReservoirFunctionMechanical39SensoryComponentsNeuropathwaysSympathetic+parasympatheticpathwaystointernalsphincter(hypogastric)Somatictoexternalsphincter(pudendal)SensoryComponentsNeuropathwa40SphincterfactorsBasaltonePressurezoneanalcanal25–120mmHg rectum5–20mmHgContinuoustoneofint.andext.sphincterincreaseswithincreasedabdominalpressureSphincterfactorsBasaltone41MechanismofAnalContinenceStructuralconsiderationsAnorectalanglebetweenrectumandanalcanalFlapvalveangleoftheanteriorrectalmucosacausedbypuborectaliscausesocclusionInternalsphincterincontinuoustonicstatewithexternalsphincterengagedduringVasalvaMechanismofAnalContinenceSt42AnalFissureUlcerinthelowerportionoftheanalcanalAcute/chronicprimary/secondarySx:analpain,duringandafterBM’sAnalFissureUlcerinthelower43AnalFissureTriadeofanalfissureanalpapillahypertrophyfissureinanosentinelpileAnalFissureTriadeofanalfis44AcuteFissureTreatmentinspection,usuallyincreasedanaltonecanbeappreciatedonrectalexamiftoleratedcleansingmeasurestypicallyresolvein6weekswithoutsurgicalinterventionAcuteFissureTreatment45ChronicFissuresentineltag,ulcer,hypertrophiedanalpapillaFormbecauseofswelling,edema,andlowgradeinflammationmaygoontofibrosisExtendsfromthedentatelinetotheanalvergeChronicFissuresentineltag,u46ChronicFissureTeatmentnitroglycerinointment0.2%-0.4%BIDTopicaldiltiazem(50%resolutionat6weeks)BotulinumtoxinAinjection–42%recurrenceat42months–sideeffectsSurgery:lateralinternalsphincterotomyChronicFissureTeatment47LateralinternalsphincterotomyLateralinternalsphincterotom48SecondaryanalfissureCrohn’sdiseaseNon-midlineorabnormalappearingfissureshouldundergomarginbiopsyAvoidsurgeryinneutropenicpatients–treatwithperinealhygineandpainreliefSecondaryanalfissureCrohn’s49AnorectalAbscessAnorectalAbscess50AnorectalAbscessInfectioninoneoftheanalglandsMaybeasymptomaticorcauseseverethrobbingpainthatresemblesafissureAbscessshouldbedrainedwhendiagnosedAnorectalAbscessInfectionin51AnorectalAbscessSx:severepain(aggravatedbywalking,straining)SwollenmassmaybeappreciatedAnorectalAbscess52AnorectalAbscessTreatmentdrainage,avoidpacking,noabscesstypicallyCrohn’sdiseaseoralmetronidazoleorciprofloxacinseemstohaveamitigatingeffectAnorectalAbscessTreatment53FistulaChronicformofperianalabscessEvaluationwithanoscopy,endoanalultrasoundClassificationFistulaChronicformofperiana54FistulaintersphincterictranssphinctericsuprasphinctericextraspinctericFistulaintersphincterictranssp55Goodsall’sruleGoodsall’srule56FistulaTreatmentUnroofingthefistula,eliminatingtheinternalopening,andestablishingadequatedrainageOlderpatientsuselooselytiedsetonstoallowforadequatedrainageFistulaTreatment57AnalfistulotomyAnalfistulotomy58Thread-drawingThread-drawing59HemorrhoidsHemorrhoids60HemorrhoidsVaricesofhemorrhoidalplexusA-Vcommunicationinanalmucosa