In ancient ayurvedic text
only single terminology is used to denote the anorectum i.e. Guda it is the
organ which actually perform‟s the act of defecation.They have even described
the embryological derivation and development of Guda, and other body organs in
Sharirasthana. It shows their ingenuity and depth of study of the human body
and its organs in those days when facilities were lacking and Sushruta
practicing surgery of performing body dissection was considered outcasts and
unsociable.
SYNONYMS :
• Apanah
• Braddhanah
• Mahat Srota
•
Payu
•
Vit Marga
Guda is the distal part of large
intestine having a length of five and half angula (finger‟s); in which there
are three vali‟s (folds) namely „Pravahini‟, „Visarjani‟ and „Samvarni‟
proximally to distally. They have the appearance of involuted indentures of
counch shell,situated one above the other and coloured like the palate of an
Elephant. The total length of vali is four fingers in which each vali having a
length of one finger which is separated from each other by a length of half
finger. Distal to the lowermost vali i.e. „samvarni‟ at a length of one finger
there is presence of „Gudostha‟ having length of one and half Yava i.e. half
finger therefore the total length of Guda including „Gudaostha‟ is about five
and half angula (finger‟s)
गुदशरीर
:-
तत्र स्थुलान्त्रप्रतिबध्दमर्द्धपञ्चांगुलं गुदमाहु ।
तस्मिन् बलयस्तिस्त्रोऽध्यर्ध्दाङ्गुलान्तरसम्भूताः
प्रवाहणी
विसर्जनि सव्ंरणी चेति ।
चातुराङ्गुलायताः सर्वस्तिर्यगेकाङ्गुलोच्छ्रिताः ।
शङ्खावर्तनिभाश्चापि उपर्युपरि संस्थिताः ॥
गजतालुनिभाश्चापि वर्णतः सम्प्रकिर्तिताः ।
रोमेन्तेभ्यो यवध्यर्ध्दो गुदौष्ठः परिकिर्तितः ।
-सु नि २/५
Formation of Guda =
आत्र,गुद,बस्ति उत्पत्ति :-
असृजः श्लेश्मणश्चापि यः प्रसदः परो मतः ।
तं पच्यमानं पित्तेन वायुश्चाप्यनुधावति ॥
ततोऽस्यान्त्राणि जायन्ते गुदं बस्तिश्च देहिनः ॥
-सु शा
४/२६
It
is formed by the Prasad bhaga of blood and Kapha, after being digested by Pitta
with the help of Vayu.
PESHIES:-
Guda
has three Peshies out of sixty six present in kostha.
पेशी वर्णन् :-
पञ्च पेशीशतानि भवन्ति । तासां चत्वारि शतानि
शाखासु कोष्ठे षट्षष्टिः ग्रीवां प्रत्यूर्ध्व चतुस्त्रिंशत् ॥
-सु शा
५/४४
DHAMANIES:-
There
are twenty four Dhamnies in the body ,out of which ten go downwards and perform
the functions of micturation, Defaecation, Ejaculation of Semen, Menstruation
and expulsion of foetus during delivery.
SHEERA’S:-
Out
of seven hundred sheera‟s present in body there are thirty four Vaata carrying
sheera‟s in Kostha; of which eight are present in Guda, Medhra and Shrooni.
Same
number‟s of Kapha, Pitta and Rakta carrying sheera‟s are present, hence total
of thirty four sheera‟s are present in Guda, Medhra and shrooni region.”
सिरा :-
तासां तु नाभिप्रभवाणां धमनीनामुर्ध्वगा दश,
दशचाधोगामिन्यः चतस्त्रस्तिर्यग्गाः ॥
-सु शा
९/४
GUDA AS MARMA:-
·
Sushruta has
described Guda as Sadhyaapraanhar Marma.
गुद मर्म :-
श्रूङ्गाट्कान्यधिपतिः शङ्खौ कण्ठसिरा
गुदम् ।
ह्रुदयं बस्तिनाभौ च घ्नन्ति
सद्योहतानि तु ॥
-सु
शा६/९
सद्योमर्म :-
तत्रवात-वर्चोनिरसनंस्थूलान्त्रप्रतिबध्दंगुदंनाममर्म,तत्रसद्योमरणम्।
-सु शा
६/२६
Charak described Guda as
Marma as well as Pranayatan i.e. where the
Prana (life) is situated.Guda is of Mamsa Marma type.
दशप्राणायतनानि
दशप्राणायतनानि,तद्यथा
मूर्धा,कण्ठ,हृदयं,नाभि,गुदं,बस्ति,ओजःशुक्रः,शोणितं,
मांसमिति । तेषु षट् पुर्वाणि मर्मसंख्यातानि ॥
-च शा
७/९
गुद मांसमर्म :-
मांसमर्म गुदान्येषां स्नाञ्नि कक्षधरौ तथा ।
-अ हृ
शा ४/४५
ASTHI :-
The visceral organs are
well protected by the bony age of Shroni. This Shroni comprises of five bones
out of them four comes are well attached with Guda, Yoni and Nitamba.and the
remaining one is in the Trika region. The Asthi Sandhi of this region is
Samudge type.
SNAYU :-
There are sixty snayus in
the Pelvic region and eighty are in the Groin. The snayus which are connected
with Guda region come under the group of Sushira.Defaecation is the most
important function of Guda
STROTAS VICHAR:-
Guda comes under the
Bahirmukha Srotos.Guda is mention as to be root of Purish vahaa strotas i.e.
faeces carrying strotas.
पुरिष् वह स्त्रो मूलस्थान :-
........पूरिषवहे द्वे तयोर्मूलं पक्वाशयो गुदं
च........।
- सु
शा ९/१२
SHARIR KRIYA OF GUDA:
Important
function of Guda is the excretion of vayu (flatus) and varchas (faecal
material); the function is controlled by „Apaan Vayu‟ with the help of three
vali‟s. The role of these three vali‟s is of prime importance in this context
शा. क्रिया :-
....मलास्यध्ः पीडनात प्रथमा
प्रवाहिणि,गुदविस्फारणेन मलविसर्जनाद् द्वितिया
विसर्जनी.गुदसङ्कोचन्याख्यपेशीद्वयकृता चक्राकारा वलिस्त्युसवंरणी नाम् ।
-सु शा
२/६,७,८
1) Pravahini vali:-
As the name suggests it
help‟s to propel or force the faecal material downwards.
2) Visarjani vali:-
Relaxes the anorectal
muscle and thus performs excretion of faeces.
3) Samvarni vali:-
It closes the anal orifice
after the faecal material is expelled by the action of Visarjani.
According to Acharya
Charaka, Guda is one of the fifteen organs belonging to Kostha. Further, he has
divided it into two parts viz., Uttar Guda and Adhar Guda. It is difficult to
make a line of demarcation between the Uttar Guda and Adhar Guda. Here the
commentator Chakrapani comments that Uttar Guda is a part of Guda which stores the
faeces and the Adhar Guda is the lower part of Guda which is related to
defaecation.
Guda-ashrit
vyadhi.
1)Arsha 2)Parikartika 3) Bhagandara 4)vidradhi
Ø Arsha
As described in Sushrut
Samhita “Arsha‟ covers a vast topic. While describing the treatment of “Guda-arsha‟ acharya Sushruta have mentioned
four modalities of treatment viz.
1) Bhesajam i.e. treatment
by medicines
2) Kshara pratisaran i.e.
local application of kshara(alkali of herbal drug)
3) Agani karma i.e. cauterisation
4) Shastra karma i.e.
surgical treatment.
Classification of Arśa
There are different
opinions of Aacharyas regarding the
classification of Arsha. They are classified on the basis of origin, bleeding
and predominance of Doshas etc. This classification is as follows:-
The classification on the basis of the origin
1. Sahaja
2. Janmottarakālaja
Sahaja Arsha is considered
to be congenital anomaly due to disorders of paternal and maternal chromosomes.
It is very difficult to diagnose because of its different size and shape.
Janmottarakālaja Arsha occurs due to the malpractices in daily life like faulty
food habits and regimen .
The classification on the basis of the bleeding
nature
Aacharya Charaka has
stated these two types of Arsha while describing the Chikitsa. He stated it as
Ardra and Sushka .Ardra also called as Starvi, are bleeding piles due to
vitiation of Asruka and Pitta mainly. Aacharya Vagbhatta has again divided it
into Vatanubandhi, Pittanubandhi and Kaphanubandhi. While other Sushka Arsha are
non bleeding pile masses due to vitiation of Vata and Kapha.
The classification on the basis of the
predominance of Doşa
It
is mainly sub division of the Janmottarkālaja type of Arsha. According toAacharya
Charaka and Vagbhatta, it is of five types while Aacharya Sushrutadifferentiates
it into four types.He omitted the Dwandaja variety. Sixtype of Arsha are
mentioned similar to Charaka in Yoga Ratnakara, MadhavaNidan, Harita Samhita
and Bangasen Samhita
The
classification on the basis of prognosis
1.
Sadhya (Curable),
2.
Yapya (Palliative)
3.
Asadhya (Incurable).
•
Sadhya variety: According to Aacharya Sushruta if the Arsha is located in the
Samvaraņi and is of single Doshika involvement and not very chronic and it will
be curable (Sadhya).
•
Yapya variety: The Arsha caused by
the simultaneous vitiation of any two Doshas and the location of Arsha in the
second Vali, the chronicity of the disease is not more than one year, it can be
considered as Yapya variety.
•
Asadhya variety: Sahaja Arsha, if caused
by the vitiation of three Doshas and if the Arsha is placed in the internal
Vali, is incurable. In addition to this if the patients develops edema in
hands, legs, face, umbilical region, anal region, testicles and if he suffers
from pain in the cardiac region, it is considered as incurable. Aacharya Charaka
stated that Arsha located in Samvarņi Vali with involvement of only one Dosha
and less chronic are treated as Sadhya. The Arsha located on second Vali i.e.
Visarjaņi with involvement of any two Doshas and the chronicity is not more
than one year are treated as Yapya. While Sahaja Arsha, situated at third Vali
i.e. Pravahiņi and having involvement of three Doshas and chronicity more than
one year are treated as Asadhya.
The classification on the basis of management
On
the basis of the treatment, Arsha can be classified into four varieties as
follows.
• Bhaishaja sadhya Arsha.
• Kshara sadhya Arsha
• Agnikarma sadhya Arsha
• Shastra sadhya Arsha
Ø Parikartika
In Ayurvedic literature a
number of conditions have been described in relation to ano-rectal region or
Guda. But such a picture is not completely found in any one of them. It is
surprising to note that although it is one of the common ailment in ano-rectal
area, still it escaped the notice of the ancient scientists. However, a
detailed exploration of literature suggests some words which clinically may
resemble these particular entity. It may be worth wile to mention here that the
Ayurvedic practitioners have recently coined a word ‘ Gud-Vidar’ to represent this condition, but this word does not have
any origin in the original classics of Ayurveda.
Description
of this condition is very much suggestive of the modern ailment fissure-in-ano
when it is limited to anal-region. Ancient literature including Vedas have a
rich description of various diseases and their management. But “Parikartika” is
not described in Vedas, and other authors have paid very poor attention to its
description as compared to other diseases. This may be attributed to excellent
general conditions, of health, hygiene and natural habitat of ancient people.
The
prodromal symptom in the words of Sushruta is pain of sharp cutting nature in
the Guda. Further he has described in chapter Vaman Virechan Vypada, there is
sort of cutting pain, sawing pain in the anus, penis, umbilical region and the
neck of the urinary bladder.
Ø Bhagandara
=
Bhagandara
derives its name from two words 'Bhaga' and 'Darana'.
Bhaga :
The term Bhaga has been used for different entities by different authors.
Darana
: means splitting or discontinuity with severe pain .
Thus,
Bhagandara is a disease which causes splitting or discontinuity in the region
of Bhaga, Basti and Guda region.
Charaka
and Vagbhata have given detailed description of general etiology of Bhagandara.
(Ch.chi. 14/ Va.Ni 8 )
Sushruta
also given the etiology of Bhagandara. (Su.Ni.4)
Vata-pitta-kapha,
prakopaka ahara & vihara,Hard stool (vegavrodha) etc.
Types =
According
to sushruta
Vataja - shataponak
Pittaja- ushtagreeva
Kaphaja- paristravi
Sannipataja - shambukavarta
Aagantuja- unamargi
According
to vagbhat
Vatapittaja- parikshepi
Vatakaphaja- ruju
Kaphapittaja- arshobhagandra.
Aacharya
Sushruta explains Abhyantara vidradhi out of which Gudagat can correlate with
Ano-rectal abscesses.
Modern Review of literature.
To understand the aetiopathogenesis of various
Ano-Rectal diseases it is wise to know the anatomy of the concerned region.
Derivation Of Rectum And Anal Canal:
- Rectum :
The rectum is derived from the primitive
rectum i.e. the dorsal subdivision of the cloaca. According to some authorities
the upper part of the rectum is derived from the hind gut proximal to the cloaca.
- Anal Canal :
The anal canal is formed partly
from the endoderm of the primitive rectum and partly from the ectoderm of the
anal pit or proctodaeum. The line of junction of the endodermal and ectodermal part
are represented by the anal valves.
Ø The anatomical anal canal extends from the anal
valves to the analverge.
Ø The surgical anal canal commences at the level
where the rectumpasses through the pelvic diaphragm and ends at the anal verge.
ANAL CANAL MUSCULATURE:
The internal sphincter is
a thickened continuation of the circular muscle coat of the rectum. This
involuntary muscle commences where the rectum passes through the pelvic
diaphragm, and ends just within the anal orifice, where its lower border can be
felt. The internal anal sphincter is 2.5 cm. long and 2 to 4 mm thick when
exposed during life, it is pearly - white in colour and its individual
transversely placed fibres can be seen clearly. Spasm and contracture of this
muscle play a major part in fissure and several other anal affections. The
conjoined longitudinal muscle is a continuation of the longitudinal muscle coat
of the rectum intermingled with fibres from the pubo-rectalis. Some of its
fibres pass through the Anal internal sphincter to reach the submucous space,
and are inserted into the fibrous tissue beneath the anoderm, but they mainly
fan out through the lowest part of the external sphincter, to be inserted into
the true Anal and perianal skin, thus constituting the corrugator cutis ani of
Ellis. Other fibres pass more laterally across the Ischio rectal, fossa, while
anteriorly fibres of this muscle are inserted into the triangular ligament, the
urethra and the apex of the prostate, thus constituting the recto-urethralis
muscle. The external sphincter, formerly subdivided into a deep, superficial
and subcutaneous portion is now considered to be one muscle. Some of its fibres
are attached posteriorly to the coccyx, while anteriorly they are inserted into
the mid-perineal point in the male, where as in the female they fuse with the
sphincter vagina. In life the external sphincter is pink in colour, and
homogenous.
The
conjoined longitudinal muscles, by traversing the internal and external
sphincters to reach their insertions, serve to brace these sphincters.
THE MUCOUS MEMBRANE:
The
pink columnar epithelium lining the rectum extends through the ano-rectal ring
into the surgical anal canal. The mucosa of the surgical Anal canal is attached
loosely to the underlying structures, and covers the internal haemorrhoidal
plexus. Passing downwards where it clothes the series of 8 to 12 longitudinal
folds known as the columns of Morgagni, the mucous membrane becomes cubical and
red in colour; above the anal valves the mucous membrane becomes plum coloured.
Just below the level of the Anal valves there is an abrupt, albeit wavy,
transition to squamous epithelium, which is parchment colour. This wavy
junction constitutes the dentate line. The squamous epithelium lining the
anatomical Anal canal is thin and shiny, and is known as the Anoderm. The
Anoderm passes imperceptibly into the pigmented skin of the anus. Below the
dentate line the anoderm is attached very firmly indeed to deeper structures.
THE DENTATE LINE
is
most important landmark both morphologically and surgically. It represents
1.
The site of fusion of the proctodaeum and post allantoic gut and
2.
The position of the Anal membrane, remnants of which may frequentlybe seen as
Anal papillae situated on the free margin of the Anal valves.
Anatomical
and Surgical importance of the Dentate line:-
1)
It forms the embryological watershed between visceral structure above and somatic
structure below.
2)
The mucosa above the line has autonomic nerve supply and is thus insensitive to
cutting and pricking where as the skin and mucosa below is supplied by the
inferior rectal branch of the pudendal nerve and is actually sensitive to these
stimulii.
3)
The anal glands open into the anal sinuses above the anal valve at this level.
Infection in an anal gland may lead to an anal abscess which may extend into
ischiorectal space and perianal space .
4)
In the finer control of continence stimulation of nerve endings in the region
of the dentate line may initiate reflex or voluantry changes on sphincter tone.
The
Dentate line seperates:-
Above
Below
Cubical
epithelium Squamous epithelium
Autonomic
nerve
Spinal nerve
(Pain
insensitive) (Very much pain
sensitive)
i.e.
Pudendal nerve
Portal
venous system
Systemic venous system
THE ANAL VALVES OF BALL are a series of transversely placed semilunar
folds linking the columns of a Morgagni. They are functionless remnants of the
fusion of the post allantoic gut with the proctodaeum.
THE CRYPTS OF MORGAGNI [ANAL CRYPTS] are small pockets between the inferior
extremities of the columns of Morgagni. Into several of these crypts, mostly
those situated posteriorly, opens one Anal gland by a narrow duct. This duct
bifurcates, and the branches pass outward to enter the internal sphincter
muscle, where often there is situated an ampulla issuing from this ampulla
there are three to six tubular sub-branches that extends into the inter
muscular connective tissue, where they end blindly. As a rule it is the caudal
branch that is furnished with sub-branches, where as the cephalad branch
remains a solitary simple tubule and therefore, when infected, is more likely
to discharge its purulent contents along the lumen of the duct than to form an
abscess. In some lower animals these glands secrete an odoriferous substance
during the rutting season; in man their function. If any, is obscure.
Some
of their cells have been shown to give a positive staining reaction for mucin,
but as the lining epithelium is mainly cubical, the mucous secreting proper of
the Anal glands must be extremely small infection of an Anal gland is the most
common cause of ano-rectal abscesses and fistulae.
The Rectum:
The
rectum extends from the third sacral vertebra to the ano-rectal ring. It
describes three lateral curves, two concave to the left [hence the left lateral
position for sigmoidoscopy and one concave to the right. The relative shortness
of the longitudinal muscle coat forms the valve of Houston that are so much in
evidence in sigmoidoscopy. Layers of the Rectum:-
As
part of large intestine it has all the four layers in wall
1)
The mucosal
2)
The submucosal
3)
The circular muscle
4)
The longitudinal muscle
The Ano - Rectal Ring:
The
Ano-rectal ring marks the junction between the rectum and the anal canal. It is
formed by the fusion of the pubo rectalis muscle, external sphincter, conjoined
longitudinal muscle, and internal sphincter. The Ano-rectal ring can be clearly
felt digitally, especially on its posterior and lateral aspects. Division of
the Ano-rectal ring results in permanent incontinence of faeces.
Fascia of the rectum:
LATERAL LIGAMENTS: Condensations of areolar tissue around the
middle rectal vessels from the lateral ligaments of the rectum. These ligaments
have to be divided during excision of the rectum.
FASCIA OF WALDEYER: the rectum can be lifted forward by blunt
dissection from the concavity of the sacrum and coccyx. When this has been
done, one finds a strong thick layer of parietal pelvic fascia adherent to the
sacrum and coccyx, known as the fascia of Waldeyer. Traced inferiorly on the
upper layer of the anococcygeal ligament, the fascia fuses with the rectum at
the ano rectal junction. The fascia of Waldeyer is clearly seen as a thick
white layer of fascia after the anococcygeal ligament has been divided during
perineal excision of the rectum. The fascia has to be divided to gain success
to the retrorectal space. If the surgeon fails to incise this ligament he will
dissect posterior to it, in which case serious haemorrhage will occur due to
injury to the sacral veins.
FASCIA OF DENONVILLIERS: Anteriorly the extra peritoneal rectum is
covered with a closely adherent layer of visceral pelvic fascia, which extend
from the anterior peritoneal reflection above to the superior layer of the
urogenital diaphragm below and laterally becomes continuous with the lateral
ligaments of the rectum. This fascia is the fascia of Denonvilliers. During
excision of the rectum for cancer, this fascia together with the rectum is
separated from the anteriorly placed seminal vesicles in the male and the
vagina in the female. At the level of the base of the prostate, the fascia of
Denonvilliers is incised transversely to develop a plane of dissection between
it and the rectum. The fascia of Denonvilliers remains adherent to the
posterior aspect of the prostate gland.
SUPPORTS OF THE RECTUM:
The
end gut is held in position by:
1.The
attachments of the levatores ani between the internal and
sphincters.
2. The visceral layer of the pelvic fascia.
3. The recto-urethralis muscle, which
attaches it to the urogenital
diaphragm
and perineal body.
4. The
rectal stalk or lateral ligament. On each side of the back of therectum, 2 – 5
cm above the levator, is a dense fibrous cord runningfrom the third piece of
the sacrum to the rectal wall. It contains the nervi erigentes (S2, S 3) and
the middle rectal arteries, and is an important structure in holding up the
rectum. The surgeon cannot draw down the rectum in the operation of perineal
excision till this ‘stalk’ is divided.
5.
The fatty tissue of the pelvis and ischiorectal fossae.
6.
The sacral curve, which is not well marked in the infant and child.
The Blood Supply:
1.
The Superior Haemorrhoidal Artery :
This
artery is the direct continuation of the inferior mesenteric artery and
constitutes the chief arterial supply to the rectum. Opposite the third sacral
vertebra the artery divides into a right and left branch, which descend on the
postero - lateral walls. About halfway down the rectum each branch subdivides
and pierces the rectal wall. The terminal branches run straight downwards each
in a column of Morgagni.
The Middle Haemorrhoidal Artery:
This
artery is usually so small as to be almost insignificant arises on each side
from the internal iliac artery and supplies the muscle coat of the mid-rectum.
These arteries anastomose freely with the superior and inferior haemorrhoidal
arteries.
The Inferior Haemorrhoidal Artery:
This
artery is arises on each side as a branch of the internal pudendal artery, as
this artery enters Alcock’s canal crossing the upper part of the Ischio rectal
fossa, it breaks up into branches which supply the anal sphincters, anal canal
and the skin of the anal margin.
The Internal Haemorrhoidal Venous Plexus:
This
lies in the loose submucosa of the anal canal and extends from the level of the
dentate line to that of the ano-rectal ring. The plexus drains into about six
collecting veins, which are situated in the submucosa of the rectum. About half
way up the rectum these branches pass through the rectal wall, and having
reached the out side of the rectum, they unite to form the superior
haemorrhoidal vein, an important tributary, of the portal vein. The middle
haemorrhoidal veins are small and drain into the internal iliac veins.
The external haemorrhoidal venous plexus:
This
lies under the skin of the anal canal below the dentate line and beneath the
skin of the anal margin. Communicating veins pass from the external
haemorrhoidal plexus to the internal haemorrhoidal plexus beneath the anoderm.
The lower part of the external haemorrhoidal plexus drains into the internal
pudendal veins and then into the internal iliac veins, thus providing a link
between the portal and systemic venous system.
The Lymphatics of the Ano-Rectum:
The
collecting lymphatic vessels of the surgical anal canal are divided into two
networks. One beneath the mucocutaneous lining and the other related to the
muscular coats. Although these are distinct systems, it becomes apparent that
there is plentiful inter communication between them, particularly along the
points of penetration of the muscular walls of the anal canal by blood vessels.
From these networks emerge three sets of lymphatic trunks referable to the
lower, middle and upper thirds of the anal canal.
The lymphatics of the rectum proper:
The
lymphatic plexuses of the rectum proper are divided into an intramural and an
extra mural group. The intramural system is redivided into two fairly distinct
territories at the level of the middle valve of Houston. The lower part of the
plexus drains downwards to join the lymphatic trunks that follows the middle
haemorrhoidal vessels; the upper trunks follows the superior haemorrhoidal
vessels to the lymph nodes in the meso rectum and meso-colon. The extra mural
plexus drains into a group of 4 to 7 lymph nodes situated above the levator
ani, in the region of the ampulla, in close relation to the rectal wall. These
are the para rectal lymph nodes of gerota. Larger lymph nodes are situated more
superiorly at the level of the third piece of the sacrum, opposite, which the
superior haemorrhoidal artery bifurcates.
Proceeding
upwards, the lymphatic trunks of both plexus pass to nodes situated at the
origin of superior haemorrhoidal artery and the sigmoidal arteries. From there
the lymphatic trunks pass to the upper most nodes grouped around the origin of
the inferior mesenteric artery. There is seldom, if ever, metastasis along the
lateral or inferior lymphatic pathways from a carcinoma situated above the
ampulla of the rectum. Hence, in general it can be stated that the higher the
growth the more confined are its metastasis. This justifies restorative
resection in cases of carcinoma high in the rectum.
Nerve supply:
Above
the dentate line the rectum and anal canal is supplied by sympathetic and
parasympathetic nerve fibres. The sympathetic supply is comprised by branches
of inferior mesenteric plexus and presacral nerves from preaortic plexus
commencing in the 2nd, 3rd and 4th lumber sympathetic ganglia, while the
parasympathetic supply comes from the 2nd, 3rd and 4th sacral
nerves. The main function of the sympathetic nerve is to inhibit the rectal
wall and stimulate the internal sphincter, where as, the parasympathetic nerves
stimulate the rectal wall and inhibit the sphincter. Afferent impulses
underlying sensations of physiological distension are conveyed by the
parasympathetic nerves, while pain impulses are conducted by both the
sympathetic and parasympathetic nerves. The inferior haemorrhoidal nerve supply
the distal portion of pectinate line and part of the external sphincter. The
external sphincter - ani is also supplied by the perineal branch of the fourth
sacral nerve.
Function:-
1)
To increase peristaltic movement and sensory activity.
2)
To open or relax internal sphincter.
Physiology Of Defecation:
Defecation
is an act of emptying of entire distal colon from the splenic flexure through
the anal orifice into the exterior, which is a reflex process. The reflex is
initiated by the rise of intra luminal pressure of about 20-25 cm of water in
the rectum containing pressure receptor, which not only detects increase of
pressure but also differentiates whether the increase in pressure is due to
gas, liquid or solid. The reflex centres have been located in the hypothalamus,
in the lower lumber and upper sacral segments of the spinal cord and in the
ganglionic plexus of the gut. This is a reflex which is under some degree of
voluntary control.
Mechanism:
The
rectum is normally empty. The faecal matter is stored in the sigmoid and pelvic
colon and not in the rectum. As soon as some faecal matter enters the rectum
due to mass movement there is a desire for defecation along with voluntary
effort e.g. assumption of appropriate posture, voluntary relaxation of external
anal sphincter and abdominal compression in the adult, etc. which may further augment
visceral reflexes. These reflexes result mass contraction of entire length of
colon and relaxation of internal anal sphincter. Thus the colon contents pass
into the pelvic colon, rectum, anal canal and finally removed from the body.
Defecation reflex can be initiated earlier or inhibited voluntarily.
Various
Ano-rectal diseases
1)
Haemorrhoids2)Anal fissure3)Anal fistulas
4)Abscess
Ø HAEMORRHOIDS
OR PILES
Dilated
tortuous veins i.e. varicosity of the vein of anal canal is known as
haemorrhoids.
Haemorrhoids
or Piles is one of the commonest ailments affecting mankind due to evolution
i.e. erect posture.
CLASSIFICATION
I)
Internal haemorrhoid:-
Arising
in upper 2/3rd of the anal canal which is lined by columnar epithelium above
dentate line.
II)
External haemorrhoid:-
Arising
in skin in lower anal canal below the dentate line.
DEGREE
OF HAEMORRHOID FORMATION
There
are four degrees of internal haemorrhoids
I)
First degree haemorrhoid ( Io )
These
merely projects slightly into the lumenof anal canal when the veins are
congested at defecation.
II)
Second degree haemorrhoid ( IIo )
These
piles tend to form swelling which not only protrude into the anal canal but
also descend towards the anal orifice so that eventually the mucosal surface
corresponding to the pile may appear externally while the patient is straining,
but return spontaneously to the anal canal when motion has passed and
defecation efforts has ceased.
III)
Third degree haemorrhoid ( IIIo )
These
piles prolapsed more readily and not only protrude during defecation but remain
prolapsed afterward until they are digitally replaced in the anus.
IV)
Fourth degree haemorrhoids ( IVo )
These piles are very large and develop considerable
skin covered component that they cannot be properlyreturned to the anal canal
but instead remain as a permanent projection of the anal mucosa
Ø Anal
Fissure =
Anal
fissures are common problems that cause severe patient discomfort. A fissure is
basically a linear tear in the anal mucosa which extends distally from the
dentate line to the anal verge. Analogous to a “split lip” of the anus, every
time a patient has a bowel movement, the anal mucosa will be stretched and the
fissure reopened. A fissure can sometimes heal by itself, but due to recurrent
injury by the mechanism described above, and often the associated increased
contraction of the internal anal sphincter, it becomes a chronic problem.
Etiology/Epidemiology =
The
etiology for anal fissures is not completely understood. Some type of initial trauma
is necessary with subsequent failure of healing. This initial insult is often a
hard bowel movement and history of constipation, although severe diarrhea can
also be an associated condition as well. Other diseases like Crohn’s disease,
HIV or previous surgery should also be considered. Failure of healing is
thought to be secondary to internal anal sphincter hypertonicity and subsequent
relative decreased blood supply.
Diagnosis =
A
thorough history is not only essential, but can often make the diagnosis alone
in this disease. Patients will describe a sharp pain that is initiated by a
bowel movement. The pain will last for a few minutes to several hours. Other
complaints will be bright red bleeding after a bowel movement that is most
commonly described as streaking the stool or on the toilet paper with wiping,
although it can occur throughout the day. If a sentinel pile is present, some
tenderness to palpation can be present. On examination spreading of the
buttocks is often enough to see the fissure and no anoscopic exam is necessary
in the acute setting. Digital rectal examination can often palpate these
fissures, although local anesthetics are recommended due to the severe pain
associated with such an exam. It is the authors’ preference to diagnose and
begin treatment (often without digital examination or anoscopy) and bring the
patient back in 2-4 weeks for a more thorough examination when the patient is
less symptomatic.
Management =
Again
conservative management is the first option in treatment. Medical management
includes oral analgesics, sitz baths, bulking agents and/or stool softeners,
increased hydration and topical anesthetics.
If
the fissure fails to heal after medical treatment, surgical intervention is
often necessary. Although many procedures have been reported, the lateral
internal sphincterotomy (LIS) is the most commonly performed. This procedure
involves division of the internal anal sphincter muscle to the level of the
proximal extent of the fissure or the dentate line through either a closed or
open procedure. This relieves the
symptoms in over 98% of patients and has very low recurrence rate. Other
surgical approaches include posterior internal sphincterotomy and manual anal
dilation which are each associated with higher complication rates of a keyhole
defect and fecal incontinence.
Ø Fistula- in- Ano
Ø Fistula
in ano is a disease of ano rectum which
is characterized by single or multiple sinuses with pulurent discharge in
perianal region.
Ø Fistulous
track lined by granulation tissue-opens deeply in the anal canal or the rectum
and superficially on the skin around the anus.
Etiology
=
Nonspecific (90%)
·
Cryptoglandular origin
Specific (10%)
·
Anorectal disease
·
Inflammatory bowel disease
·
Infections
·
Malignancy
·
Trauma
Some other causes
·
Previous pyogenic abscess
·
Tuberculosis
·
Ulcerative colitis
·
Crohn’s disease
·
Other abdominal disease leading to
formation of pelvic abscess.
Signs
& Symptoms =
·
External opening : A boil in the perianal
region with purulent, or serous discharge with skin irritation.
·
Intermittent swelling, pain, and fever.
·
Chronic draining sinus.
·
Sometimes multiple ext. openings-
“watering-can” appearance.
·
Internal opening as a fibrous dimple may be
seen or felt in digital exam.
Classification =
·
Sub-cutaneous fistula
·
Sub-mucus fistula
·
Inter-sphincteric fistula
·
Trans-sphincteric or Ischiorectal fistula
·
Extra-sphincteric or Pelvirectal fistula
MILLIGAN
& MORGAN (1934) & GOLIGHER (1975)
·
SUBCUTANEOUS (5%)
·
LOW ANAL (75%)
· HIGH
ANAL (8%)
·
ANORECTAL(7%)
·
ISCHIORECTAL OR INFRALEVATOR
·
PELVECTAL OR SUPRALEVATOR
·
SUBMUCOUS (OR HIGH INTERMUSCULAR) (5%)
Anorectal
Abscess=
An
anorectal abscess is essentially a “boil” of the perianal/perirectal region,
with the purulent collection developing as the acute manifestation, and the
anal fistula resulting as a consequence of this initial infection.
Etiology/Epidemiology
=
The etiology of these abscesses is thought to be
cryptoglandular in approximately 80% with the remaining 20% being from trauma, HIV,
cancer, or inflammatory bowel disease . These very common infectious processes
develop when there is an obstruction of an anal crypt at the dentate line in
the anal canal. The anal gland emptying into that crypt then becomes infected
and, depending on the exact location of the infection, a perianal or perirectal
abscess arises. Such an abscess is either drained surgically or drains spontaneously.
If the opening to the anal crypt does not heal completely, this becomes the
internal opening of a fistulous tract that drains through the external opening
on the anus or buttock where the abscess originally drained.
Diagnosis
=
Common presenting symptoms
for abscesses include pain, swelling and other general signs of an infection,
including fever, especially in ischiorectal and supralevator abscesses. The
pain is classically severe in the perianal or perirectal region, and mostly
gradual in onset. Pain is not often associated with fistulas, where drainage
and occasional bleeding is more common. On examination, a tender fluctuant mass
can be seen if a perianal abscess is present.Unfortunately, patients with intersphincteric,
supralevator and deep post-anal space abscesses may have a paucity of findings
other than tenderness with digital rectal examination.
Management
A simple abscess without a
fistula can be incised, drained and the wound left open for continued drainage.
An elliptical or cruciate incision is often preferred. Perianal and
ischiorectal abscesses can be drained in the OT with the aid of anesthetics. If the abscess is large, the patient
is febrile, or other types of abscesses are suspected (i.e., supralevator, deep
postanal space, horseshoe abscess) it is best performed, if possible, in the
operating room under general anesthetics.
Ø Complications
Post-operative
complications include recurrence of the abscess or fistula.
Complications
of Ano-rectal surgery =
·
Primary haemorrhage
·
Secondary haemorrhage & sepsis
·
Anal stenosis
·
Anal incontinence
Management
of haemorrhage =
·
Anal packing
·
Haemostatic agents – adrenaline / Sepgard
pack.
·
Cauterization or ligature under anaesthesia
Anal
stenosis =
·
Anoplasty
Anal
incontinence =
·
Sphincter exercises
· Sphincter
repair
· Graciloplasty
/ Gluteus maximus repair
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