Benign perianal conditions

Dr Tony MakTeam 3Refresher course21‐6‐2013

Benign Perianal Conditions

• Haemorrhoids

• Fistula‐in‐ano

• Anal Fissure

• Rectal prolapse

• Perianal Sexually transmitted diseases

• Pilonidal sinus

Basic assessments

• Bleeding

• Pain

• Pruritus Ani

• Swelling

• Tenesmus

• Discharge

Bleeding

• Haemorrhoidal bleeding:

bright red

separate

paper and bowl 

may drip

• Beware:

darker bleeding

bleeding mixed with stools

Anal pain• Character?   Sharp / Dull

• When? Pain on defecation

• Duration? Lasts few days…… prolonged

• Associated symptoms…..  Swinging Fever……. Local swelling

• Proctalgia fugax

• Severe spasm of anal pain

• Last only a few minutes

• Often at night

Pruritus AniSystemic illness

Diabetes mellitus

Hyperbilirubinemia

Leukemia

Aplastic anemia

Thyroid disease

Mechanical factors

Chronic diarrhea

Chronic constipation

Anal incontinence

Soaps, deodorants, perfumes

Over‐vigorous cleansing

Hemorrhoids producing leakage

Prolapsed hemorrhoids

Alcohol‐based anal wipes

Rectal prolapse

Anal papilloma

Anal fissure

Anal fistula

Tight‐fitting clothes

Allergy to dyes in toilet paper

Intolerance to fabric softener

Food sensitivity

Tomatoes

Caffeinated beverages

Beer

Citrus products

Milk products

Dermatological conditions

Psoriasis

Seborrheic dermatitis

Intertrigo

Neurodermatitis

Bowen's disease

Various squamous disorders

Atopic dermatitis

Lichen planus

Lichen sclerosis

Contact dermatitis

Infections

Erythrasma (Corynebacterium)

Intertrigo (Candida)

Herpes simplex virus

Human papillomavirus

Pinworms (Enterobius)

Scabies

Medications

Colchicine

Quinidine

Perianal swelling• Where is it??

• Does it comes and goes?

• Is it getting bigger?

• Hard or soft?

Examination• Inspection

• Scars

• External opening/Sinus

• Lesions: fissures, thrombosed haemorrhoids, condyloma

• Skin conditions: dermatitis

• Palpation

• Painful?

• Induration

• Lesions: Fibroepithelial polyps, low rectal tumours

• Anal tone

• Rigid endoscopies (Rectum and Anal canal)

• Visual confirmation

Haemorrhoids

Famous people with troublesome haemorrhoids….

Were Napoleon’s haemorrhoids the cause of his defeat at the Battle of Waterloo?

Karl Marx (1818‐1883)

Ernest Hemingway (1899‐1961)

?

Most patients assume problems with their bottoms are due to piles

Haemorrhoids are common,at least 50% of people will suffer

symptoms at some time

Anal vascular cushions contribute to anal closure

Haemorrhoids: blood supply

• 6 (4‐8) terminal branches of Superior rectal artery

Terminal branches from Superior Rectal Artery

3

711

Left lateralLeft lateral

Right posteriorRight posteriorRight anteriorRight anterior

Anal Cushions: constant positionAnal Cushions: constant position

Gradual loss of support of anal cushions

Detach from internal sphincter

Loose and bulge into anal canalDilatation & engorgement of AV plexuses

Aetiology of haemorrhoids

Aetiology of haemorrhoids

Thomson Thomson ‐‐ ““Vascular Cushion TheoryVascular Cushion Theory””

Anatomical support weakens

Aging (deterioration after the third decades)

Straining, increased abdo pressure

Hormonal influence

Genetic predisposition

Classification – anatomical origin

Internal Internal haemorrhoidshaemorrhoids (endoderm)(endoderm) Arise above the dentate line

Microscopically covered by transitional or columnar epithelium

Lack of somatic sensation

External External haemorrhoidshaemorrhoids (ectoderm)(ectoderm) Situated below dentate line

Microscopically covered by modified skin epithelium 

Goligher Grading

No protrusion of No protrusion of haemorrhoidshaemorrhoids

Stage I

Protruding haemorrhoids Protruding haemorrhoids that spontaneously that spontaneously reducereduce

Haemorrhoids

Stage III

Protruding Protruding haemorrhoids, haemorrhoids, possible possible to push back in to push back in manuallymanually

Protruding Protruding haemorrhoidshaemorrhoidsthat canthat can‘‘t be pushed back t be pushed back in manually anymore in manually anymore

Stage IVStage II

Bleeding

• Haemorrhoidal bleeding:

bright red

separate

paper and bowl 

may drip

• Beware:

darker bleeding

bleeding mixed with stools

Haemorrhoidal symptoms

• Bleeding

• Prolapse

• Burning or pressure sensation

• Pain (when thrombosed)

• Pruritis ani

• Anaemic symptoms

Also associated with many other anal pathologies

Differential diagnosis

• Anal/rectal cancer

• Perianal haematoma

• Fissure‐in‐ano

• Anal skin tags

• Anal warts

• Prolapse

• Perianal Crohn’s disease

Who do I investigate ?

Conservative therapy

• Diet

• Wt loss

• Avoid Straining

• Stool softeners

• Topical creams

Principles of invasive procedures

1. Fixation Injection sclerotherapy

Rubber band ligation

Thermal methods

PPH

2. Excision Haemorrhoidectomy

3. Destruction of haemorrhoidal arteries DG‐ HAL / THD

Laser photocoagulation

Procedures carried out in ClinicProcedures carried out in Clinic

5% Phenol in almond oil

INJECTION SCLEROTHERAPY

First and Second Degree where bleeding is principle symptom.

Irritant sclerosant solution (phenol in oil) injected into submucosaproximal to each haemorrhoidal plexus

Simple, safe , painless

Complications related to incorrect application.

Long-term success rate - sparsely reported.

RUBBER BAND LIGATION

• Local obliteration of submucosal vessels• Ischaemic necrosis• Ulceration (7‐10 days post banding)• Fixation of mucosa by fibrosis (the area healed by 3‐4 weeks)

• 79% symptomatic control but approximately 33% relapse at 5 years

• Complications: pain, bleeding, post banding sepsis

Apply the band at least1cm above dentate line

Maximum: up to 3 banding

Can be repeated

Thermal Methods

• Thermal methods has been used for hundreds of years ranging from heating to freezing

Infrared

Laser

Diathermy

Cryotherapy

Infrared Thermocoagulation• Infrared radiation penetrates the tissue to a predetermined depth

• Instantly converted into heat (slightly above 100 0C) protein denaturation

• Coagulate vessels & fix the mucosa to underlying tissues

Results

• Safe and well‐tolerated clinic procedure

• Works best with small 1st / 2nd degree piles

• Almost immediate return to normal activity

• Less post‐treatment discomfort than RBL

Poen et al 2000 Eur J Gastroenterol hepatol 

• Inferior to rubber band ligation Higher rate of recurrence (54% vs 27%)

Walker et al 1990 Int J Colorectal Dis

Need multiple treatments

Procedures in clinic ‐ Caution

• Bacteraemia 

Beware of existing cardiac disease

Presence of metallic heart valve

Newly implanted vascular graft / artificial joint

• Anti‐coagulant Therapy

• Clopidogrel

Consider inConsider in--patient treatmentpatient treatment

Management of Haemorrhoidal Disease

“For many years there has been an increasing tendency to perform less and less surgery for haemorrhoids. This follows on from the expectation on behalf of patients and surgeon that haemorrhoidectomy is extremely painful and requires prolonged hospital stay and time off work.However, all surgeons are familiar with the frequency at which patients re‐attend over many years when treated by injection sclerotherapy and rubber band ligation.”

Peter Loder, “Colorectal Surgery, A Companion to Specialist Surgical Practice” Chapter 13 (Edited by Robin K Phillips)

OPERATIVE HAEMORRHOIDECTOMY

Classification of HaemorrhoidsDegree of prolapse

1st degree - No prolapse 2nd degree - Spontaneously reducible

3rd degree - Prolapse requiring manual reduction Fourth degree - Permanent prolapse

HAEMORRHOIDECTOMY

• Surgical excision is one of the oldest treatments for piles

• Most effective and long‐term cure

• <5% recurrence rate

• Several described techniques

• None has been shown to be the best

OPEN HAEMORRHOIDECTOMY

III/IV Degree

Milligan-Morgan (1937)

General Anaesthetic

External component and internal

haemorrhoids grasped with forceps

and retracted.

Dissection of external haemorrhoidal tissue off internal sphincter.

Dissection continues to top of anal cushion

Pedicle is ligated and transected

(ligature may be unnecessary with diathermy)

Defects left open leaving three raw areas

separated by bridge of skin and mucosa

“3-leaf Clover”

Healing in 5 -6 weeks

OPEN HAEMORRHOIDECTOMY

CLOSED HAEMORRHOIDECTOMY

Ferguson (1959)

Haemorrhoidectomy with primary repair

Preferred technique in USA

Prone, jack-knife position

Defect closed with continuous suture

Improves healing?

Less painful?

Reduces stenosis?

Post-op morbidity similar

Risk of wound dehiscence

Technical modifications• Energy source for dissection

• Minimize bleeding

• Avoid pedicle transfixion

• Minimize post‐op pain

Complications

Operator dependant

Often done as day cases but still painful

Urinary Retention 10-32%

Formation of skin tags 6%

Bleeding 2-4%

Anal Fissure 1-2.6%

Anal stenosis 1%

Incontinence <0.4%

Urinary retention

• The most common complication

• Predisposing factors:Pain and anal spasm

Fluid overload

Rectal packing

Drugs (narcotics, anticholinergics)

Pre‐existing outflow tract obstruction

• Leave the catheter for 24 hrs (RU > 500ml)

Haemorrhage

• Reactional haemorrhage

Technical error

Requires immediate surgical intervention

• Delayed haemorrhage (D7‐10 post‐op)

Ranging from mild‐massive bleeding

Warrants examination

Occurs in 2% haemorrhoidectomies

Sepsis in the pedicle

Usually not a preventable complication

Motives behind new development

• Pain

• Hospital stay

• Resume normal activity

• Wound discomfort

• Discharge

• bleeding

• Continence disturbance

Treatment of haemorrhoidal disease by reduction of the mucosa and haemorrhoidal prolapse with a circular suturing device:A New Procedure

Antonio LongoUniversita di Palermo

Proceedings of the 6th World Congress of Endoscopic Surgeryand 6th International Congress of European Association for Endoscopic Surgery (EAES) 777‐84Rome, Italy. 3‐6 June 1998

Procedure for Prolapse and Haemorrhoids

The Longo Technique

PPH-03 Kit

Haemorrhoidal Circular Stapler HCS 33mm

Suture Threader

Dilator

Purse-String Suture Anoscope

Remaining externalcomponent

12 trials, 955 patients

Stapled Haemorrhoidectomy – more likely to have recurrent haemorrhoids– C/O symptoms of prolapse.

2010

Stapled haemorrhoidectomy  concerns

The ACPGBI consensus document stated that adverse events were related to the possibility of a full thickness excision to the rectal wall, with the potential for injury to the internal anal sphincter. In addition, stretching of the anal sphincter by the stapler head may, in theory, cause injury.

Interventional procedure guidance 34 Dec 2003

Interrupting the arterial inflow to anal cushions

Doppler‐guided HALOHaemorrhoidal artery ligation operation

• Introduced in 1995 Morinaga K

• Identification and ligation of the terminal branches of the superior rectal artery

• Proctoscope equipped with a doppler probe

Haemorrhoidal artery ligation

Doppler US to identify arteries

Usually (3 ‐ 7) feeding arteries ligated using absorbable sutures

Recto Anal Repair (RAR)

Continuous absorbable sutures used to fix the haemorroidal prolapse back in its original position by means of mucopexy 

Before

After

Transanal Haemorrhoid  Dearterialisation• Identify the haemorrhoidal arteries (originate from sup rectal artery) at 2‐3cm above dentate line

• Suture them 

• Lift the redundant prolapse by running sutures down to 5mm above dentate line

• Fix the cushion back into anal canal 

Do

pp

ler

tran

sdu

cer

Do

pp

ler

tran

sdu

cer

HALO outcomes

• Less post operative pain

• Resolution of haemorrhoids 

• Relief of symptoms

Bleeding 

Prolapse

Pain

Itching

National Institute for Health and Clinical Excellence

Current evidence on haemorrhoidal artery ligation shows that this procedure is an efficacious alternative to conventional haemorrhoidectomy or stapled haemorrhoidopexy in the short and medium term, and that there are no major safety concerns. 

Interventional procedure guidance 342 May 2010

Clinical outcome following Doppler‐guided haemorrhoidal artery ligation: A Systematic ReviewPoucher et al Colorectal Diseases 2013

• 28 studies, 2904 patients

• Poor quality studies

• Operation time 19 – 35mins

• Recurrence rate 3 – 60%

• Safe & efficacious with low level of post op patin.

• Safe to be considered for treatment of grade II/III haemorrhoids

Thrombosed internal haemorrhoids

• Significant prolapse• Gripped by the anal sphincter• Venous return obstructed• Edema and thrombosis set in• Pain promotes reflex sphincter spasm• Vicious cycle of spasm and swelling

Acutely prolapsed haemorrhoids

Treatment• Manage conservativelyRelief of pain

Resolution of the pathology

Analgesics

Stool softeners

Ice packs

Elevate 

• Avoid surgery

• BUT….. Emergency haemorrhoidectomy

Thrombosed external haemorrhoid

• Acute perianal haematoma

• Rupture /  thrombosis (external vein) at a single / multiple sites

• Sudden sharp rise in intraluminal pressure (forceful straining)

• Painful bluish tense lump

Perianal haematoma(thrombosed external haemorrhoid)

• Management: acute

Evacuate haematoma

• Management: chronic

Leave alone

Stool softeners

Analgesics

Local anaesthetic

Clinical course• Acute stage (24‐48 hrs) 

Pain and edema

• Pain resolved in 7‐10 days

• Spontaneous discharge of clot leaving a temporary crater

• Complete healing (<3 weeks)

Summary

• Haemorrhoids are a common problem

• Consider differential diagnoses

• Try conservatively first!!

• First degree RBL or Injection sclerotherapy

• Second degree RBL / HALO / Staple

• Third degree RBL / HALO/ haemorrhoidectomy /Staple 

• Forth degree haemorrhoidectomy 

Fistula‐in‐ano

Definition

• 1882 Goodsall and Miles 

• �Complete, Blind external, Blind internal• Subcutaneous, Submuscular, Submucosal

• 1934 Milligan and Morgan

• Low or Anorectal

• 1959 Steltzner

• Intersphincteric, Transphincteric, Extrasphincteric

• 1962 Thompson

• Simple and Complex: relation to puborectalis

Halligan S , Stoker J Radiology 2006;239:18-33

1976 Parks et al.

High or Low?• High

• At or above the anal sphincter complex

• Involving large amount of muscle

• Low

• Below anal sphincter complex

• Involving minimal muscle fibre

Simple or Complex?

• Simple

• Single tract

• Low transphincteric tracts which cross <30% of external sphincter

• Often follows Goodsall’s rule

• Complex

• Multiple tracts

• High transsphincteric Suprasphincteric Extrasphincteric 

• Associated Abscesses

• Underlying pathologies

• Anovaginal fistulas

• Horseshoe fistulas

• Repeated operations

• Often does not follow Goodsall’s rule

External opening situated behind the transverse anal line will open into the anal canal in the midline posteriorly. 

Anterior opening is usually associated with a radial tract.

ComplexHorseshoe fistula

Complex FistulaAnterior Type Females

Complex FistulaCrohn’s

Complex FistulaMalignancy

Aetiology

Causes of FIA

Cryptoglandular- ~90%

Causes of FIA• Crohn’s disease

• Tuberculosis

• Hydradenitis Suppurativa

• Actinomycosis

• Malignancy

• Radiation

• HIV

• Foreign bodies

• Trauma

Crohn’s disease

Radiation-induced rectovaginal fistula

Management

• Sepsis‐ drainage close to anal verge

• Nutrition

• Anatomy + eradicate fistulous tract

• Preserving sphincter function

• Treat underlying cause

Do not delay treatment of sepsis!

UK: ACPGBI 2006 US: ASCRS 2011

Investigations 

• EUA +/‐ insertion of seton (loose) +/‐ drainage of sepsis

• Fistulography – low accuracy

• MRI rectum +/‐ Endocoil >90%

• Endoanal USS – 80%‐89% • 3D …. Comparable to MRI

• Anorectal Manometry

• Colonoscopy

• CT abdomen + Pelvis

Treatment options: Complex/high fistula

• Use of seton and staged fistulo/ectomy

• Advancement flaps

• Fibrin glue injection

• Fistula collagen plugs

• LIFT procedure

• Stem Cells

• Defunctioning

EUA + fistulotomy + seton

• Seton can be used in a staged fashion

• Initial placement as “loose” to control sepsis

• Followed by second stage procedure• Advancement flap

• Fibrin glue

• Anal plug

• Fistulotomy can be used to shorten the tract (down to the sphincter)

• Fistulectomy can be used if tract is away from sphincter

• Cutting Seton‐ less common for complex fistula

Seton insertion

Seton

EUA + fistulectomy + seton

Post‐fistulectomy wound

EUA + Fistulo/ectomy + Seton

ACPGBI ASCRS

Advancement flap• Involves curettage of the tract

• Mobilisation of “flap” to cover the internal opening

• Recurrance rate of 13% to 56%

• Quality of the flap seems to be related to failure‐ Crohns, Radiation, Active Proctitis, ischaemia

• “U” shaped flap recommended

• Sphincter function may be affected

Advancement flap

Advancement flap

Advancement flap

Advancement flap

Jarrar et al. 2011

Advancement flap

ACPGBI ASCRS

Fibrin glue injection

• Wide range of healing rate in non‐randomised series: 10%‐67%

• Randomised trial n=29• Fibrin glue vs conventional

• 1° healing rate

• Complex tracts 

• 69% vs 13%

Fibrin glue injection

ACPGBI ASCRS

Surgisis® anal fistula plug (AFP)

• A biodegradable lyophilized porcine submucosal plug 

(collagen plug)

• Acts as a scaffold for host tissue incorporation and 

remodeling

High intersphincteric FIA

External opening

Probing of internal opening

Irrigation with H2O2

Rehydration of AFP

AFP insertion

Closure of internal opening

External opening (final)

Surgisis®AFP – the procedure• Initial report promising

• Healing rates for complex fistula – 71% to 81% at 1 year Follow‐up

• Complex fistula

• Healing rates ranges from 10%‐67%

Ellis et al. 2010

Anal Fistula Plug

ACPGBI

• Insufficient evidence

• But FIAT 500 currently recruiting• Trial ends 2015

ASCRS

LIFT• Ligation of the Intersphincteric Fistula Tract

• Placement of seton‐ tract fibrosis

• Via intersphincteric plane‐ tract is idenitfied then ligated

+/‐ closure of internal opening

+/‐ widening of external opening

Complex FistulaLIFT Procedure

Complex FistulaLIFT Procedure

Complex FistulaLIFT Procedure

LIFT

ACPGBI

• Was not available

ASCRS

Crohn’s fistula• 40% to 80% of Crohn’s patients

• Drain Sepsis

• Apply loose seton

• Avoid unnecessary tissue destruction

• Antibiotics

• Infliximab (Remicade®)

• Long‐term seton 

• Diversion stoma 

• Proctectomy

Crohn’s fistula

ACPGBI ASCRS

Malignant fistula

Malignant fistula

Malignant fistula

Malignant fistula

Malignant fistula

Malignant fistula

Malignant fistula

ACPGBI

• Bx for Longstanding fistulas

Others

Anal fistuloscopy

Anal fistuloscopy

• Direct visualization of 

fistula tracts

• Identify additional 

fistula tracts and 

primary openings

• Potential therapeutic 

options

Johnson EK et al. ASCRS Annual Meeting 2005.

Anal fistulotomy with radiofrequency

• Advantages over conventional 

fistulotomy:

• Shorter operative time

• Less blood loss

• Less pain

• Shorter hospital stay

• Earlier return to normal activity

• Shorter wound‐healing time

Gupta PJ. Curr Surg 2003; 60: 524-8.

Stem cells• Adipose‐derived Mesenchymal stem cells

• Small number study

• 20‐60 million ASCs

• 71% healing compared to 16%

• Recurrance rate of 17.6% after 1 year

• Expensive and requires specialised laboratory

Conclusion

• Complex fistula‐in‐ano requires detailed investigation

• Understanding underlying pathology is essential

• Treatment of Sepsis, Preservation of  Continence, Eradicate fistula tracts

• Clinical judgement and experience is important

QUIZ……..What is this?

What fruit does it look like?

How can it be treated?

Perianal Haematoma

Treatment:

Conservative

Or

Incise and evacuate

Fissure‐in‐ano

Fissure­in­ano

• Symptoms

Bleeding

Pain‐on‐defecation

• Findings

Spasm

Tenderness

Visible fissure

Sentinel pile

Sentinel pile

Fissure‐in‐ano• Chronic fissure:

• non‐healing fissure >6weeks despite treatment

• Visible sphincter

• Evidence of sentinel pile.

• Usually at 6 O’clock but  2.5‐10%@12 O’clock

• Multiple fissures‐ IBD/TB/Syphilis/HIV

Fissure‐in‐ano

• Aetiology

• ?Constipation

• ?Internal sphincter hypertonia

• Lack of blood supply

Treatments• Conservative

• High Fibre / Increased Water intake

• Local anaesthetic gel

• 0.02% GTN ointment

• 0.2% Diltiazem ointment

• Botox injection 50 IU

• Surgical

• Lateral Sphincterotomy

Anal skin tags

Anal skin tags• Treatment

• Conservative

• Surgical

• Excision

Perianal Crohn’s Disease

• Treatment

• Conservative!!! 

• Leave them alone!!!

Rectal Prolapse

Full thickness prolapseFull thickness prolapseMucosal prolapseMucosal prolapse

These patients need referringThese patients need referring

What is rectal prolapse?

• Full‐Thickness rectal prolapse describes the entire rectum protruding through the anus 

• Mucosal prolapse describes only the rectal mucosa (not the entire wall) prolapsing 

• Internal intussusception where the rectum collapses but does not exit the anus. 

Investigation + Treatment• Clinical examination

• Full colonoscopic assessment

• Examination under anaethesia

• Mucosal prolapse

• Mucosectomy / Rubber band ligation

• Full thickness prolapse

• Abdominal approach

• Open/Laparoscopic +/‐ large bowel resection

• Ventral mesh rectopexy

• Suture/Mesh rectopexy

• Perineal approach

• Delorme’s operation

• Altemeier’s operation

Incarceration• An incarcerated rectal prolapse is rare. 

• Sugar!!• Emergency resection is required if the prolapse cannot be reduced and the viability of the bowel is in question.

Abdominal procedures• Suture rectopexy

• Mesh rectopexy

• Resection rectopexy

• Lap vs Open

Posterior suture rectopexy

First described by Cutait in 1959Mobilisation an upward fixation by fibrosis and suturing

Recurrence 0-9%

Posterior mesh rectopexy

To create more fibrosis – Sponge used by Wells in 1959Also a variety of absorbable and non absorbable meshes

Resection rectopexy

• Resection of redundant rectosigmoid

• Straight course of left colon – more fixation

• Relief of constipation

Posterior mesh rectopexy• Low recurrence and low mortality

• Pelvic sepsis – 2‐16%

• Haematoma should be avoided by draining pelvis (esp if  considerable ooze)

• Incontinence improved but constipation made worse

Ventral rectopexy

Perineal approach• Low morbidity

• Possibly high recurrence rates

• Avoids abdominal surgery and pelvic dissection

• ‘cutting off an upturned sock – not fixing it’

Delorme’s operation

Delormes• Mortality 0 ‐ 4%

• Recurrence 0 ‐ 38%

• Improvement in constipation – 13‐100%, Incontinence – 32‐67%

Altemeier’s operation

Altemeier

• Recurrence 0‐16%

Summary of resultsRecurrence

•Delormes 0‐38%

•Altemeier  0‐16%

•Posterior suture rectopexy   0‐9%

•Mesh posterior rectopexy 0‐6%

•Resection rectopexy 0‐5%

•Post operative constipation in up to 50% of rectopexy patients

Sexually transmitted disease

STDs• Bacterial

• Campylobacter jejuni

• Chlamydia

• Gonorrhoea

• Syphilis

• Parastitic

• Amoebiasis

• Cryptosporidium

• Isospora

• Virus

• Human immunodeficiency virus

• Human papilloma virus

Condylomata acuminatum(aka. Anal Warts)

Condylomata accuminatum• Most common STD seen by colorectal surgeons

• Human papilloma virus: 

• 6,11 Most common

• 16,18  More aggressive

• Treatment: 

• Excision/Cryotherapy/Laser/Immunotherapy

• Podophyllin/podophyllotoxin/ Bichloroacetic acid (BCAA)

• Interferon

Perianal syphilis

Gonorrhea

QUIZ?

?

Pilonidal sinus• Subcutaneous sinus containing hair

• Lined by granulation tissue

• Usually in natal cleft

• Foreign body reaction

• Rx:

• Advise pt to keep area hairless

• Elective

• Excision

• Phenol injection

• Skin flap

• Emergency

• Incision and drainage

Pilonidal disease

Nature Clinical Practice Gastroenterology & Hepatology (2009) 6, 20-22

Bascom procedure

Nature Clinical Practice Gastroenterology & Hepatology (2009) 6, 20-22

Thank you