Ano rectal problems ppt

Ano rectal Problems
• Presented By –
Prof.Dr.R.R.Deshpande
(M.D in Ayurvdic
Medicine & M.D. in
Ayurvedic Physiology)
• www.ayurvedicfriend.c
om
• Mobile – 922 68 10 630
• professordeshpande@g
mail.com
2/6/2017 Prof.Dr.R.R.Deshpande 1

Contents of this PPT
• 1) Anatomical Aspect
• 2) Acute Constipation
• 3) Chronic Constipation
• 4) Congenital problems
• 5) Anal Stenosis
• 6) Anorecatl agenesis
2/6/2017 2Prof.Dr.R.R.Deshpande

• 7) Piles
• 8) Fissure in Ano
• 9) Fistula in Ano
• 10) Prolapse of Rectum
• 11) Pilonidal Sinus
• 12) Stricture of Anus & Rectum

• 13) Condyloma
• 14) Carcinoma of Rectum
• 15) Pruritus Ani
• 16) Ano Rectal pain
• 17) Anal Incontinence
• 18) Proctitis
• 19) Rectal Polyp
• 20) Ayurvedic Treatments

Anatomy of Anorectal region –
Rectum
• Distal part of colon .Sogmoid colon above &
anal canal below
• 3 cardinal features ( Taeniae coli ,
Haustrations, Appendices epiploicae ) of
colon are absent
• Pelvic organ – situated in posterior part of
lesser pelvis – in front of lower 3 sacral
vertebrae

Rectum
• Diameter – 5 inches .Lower part is dilated to
form Rectal Ampulla
• Lower 1/3rd of rectum is devoid of peritoneum
• Fold of peritoneum between –urinary bladder
& rectum ,in males – Recto vesical pouch
• Fold of peritoneum between – Uterus ,cervix
,vagiba & rectum ,in Females – Recto uterine
pouch

Rectum
• Blood supply – Superior rectal
,Medial rectal, Median sacral artery
• Venous drainage – Superior & Middle
rectal vein
• Nerve supply – Sympathetic from L1
& 2 , Parasympathetic from S 2,3,4

Rectum
• Applied Anatomy –
• PR Examination for BPH etc
• Examination of Rectal mucosa –
Proctoscopy or Sigmoidoscopy
• Prolapse of Rectum – Rectum comes
out through anus

Anatomy of Anal canal
• Terminal part of colon .Situated below
the Pelvic diaphragm ,in anal triangle of
peritoneum ,between right & left ischio
rectal fossa .3.8 cm long .Extends from
Ano rectal junction to anus
• 3 parts – Upper mucous part ,Middle
transitional zone, Lower cutaneous part

• 1 . Upper mucous part – 15 mm long ,lined by
mucous membrane .Mucous membrane
shows 6 to 10 vertical folds – Anal column
• Lower end of anal column are united to each
other by transverse fold of mucous
membrane = Anal valves
• Anal valves together forms ,a transverse line
= Pectinate line

• 2 . Middle part or Transitional zone –
15 mm long ,Do not contain anal
columns .
• White line of Hilton = Lower limit of
Pecten

• 3 . Cutaneous part -- 8 mm long .Contain
sweat & sebaceous glands
• Muscles of Anal canal – Internal anal
sphincter ( Involuntary) & External anal
sphincter ( Voluntary) – subcutaneous part ,
superficial part , deep part

• Nerve supply –External anal sphincter –
supplied by Inferior rectal nerve & 4th sacral
nerve
• Blood supply --- Anal canal ,above the
Pectinate line is supplied by – superior rectal
artery & below the pectinate line by –
Inferior Rectal artery

• Venous drainage –
• 1.Internal Rectal venous plexus
• ( Haemorrhoidal Plexus ) – Lies in submucosa
of the anal canal .Drains into superior rectal
vein .Internal rectal venous plexus is an
important site of Porta caval Anastomasis
• The veins present at 3 ,7 & 11 o clock are
potential sites for primary Internal piles

• External Rectal venous plexus – Freely
communicates with the Internal rectal venous
plexus
• Anal veins – Arranges radially around the
anal margin .Excessive straining during
defaecation rupture the anal veins – forms
sub cutaneous haematoma = External Piles

• 1.Internal or True Piles – Dilation of Internal
Rectal venous plexus – classified into 2 groups
• Primary True Piles – Dilation of Internal Rectal
venous plexus at 3,7,& 11 o clock
• Secondary True Piles – Dilation of other than
above sites

• 2. External or False Piles – Rupture of anal
veins ,causing sub cutaneous haematoma
.External Piles – No bleeding ,but painful
• 3.Anal Fissure – Rupture of anal valve .Painful
with blood sticked to faeces

Anatomy of Anus
• 4.Fistula in Ano – Abnormal epithelized tract
,containing 2 cavities or 1 cavity with the
exterior outer opening of anal canal .4 cm
below & in front of tip of coccyx
• Skin around anus is pigmented
• Thrown into radiating folds .Contain ring of
Apocrine gland – keeping anus moist with
typical foul smell

Acute Constipation causes
• 1) Local pain at anus – painful fissure, perianal
abscess.
• 2) Elderly bed ridden patient.
• 3) Pregnancy.
• 4) Constipation with colicky pain in abdomen,Board
like rigidity, abdominal distention or vomiting-
Intestinal obstruction. (hyper peristalsis) or paralytic
ileus (No peristalsis) or Acute Abdomen.
• 5) Idiopathic functional constipation.

Anal Fissure

Acute Constipation- Treatment 1
• 1) For perianal abscess – Incision & drainage.
• 2) For fissure in Ano –
- Local – Xylocaine oint.
- Cap Mox – 500 mg TDS.
- Tab Tini – 300 mg – 1 BD.
- Tab Voveron – 100 mg – 1 BD.
- Tab Triphala vati – 2 H.S.

Acute Constipation- Treatment 2
• 3) For idiopathic constipation –
- Tab Herbolax (Himalaya) 3 H.S or
Abhayaristha – 3 tsf with equal quantity of
water-BD.
• 4) For Acute Abdomen –
- Admit Immediately.

Chronic Constipation – causes 1
(Habitual Constipation)
• Lack of exercise (especially
abdominal muscle exercises – poor
abdominal muscle tone.)
• Lack of roughage (Green vegetables,
fruits, raw bananas) in Diet.

Chronic Constipation causes 2
• Drinking Less water or beverages.
• Tobacco, Mawa, smoking.
• Drugs (Anti-hypertensives, antacids,
Iron, NSAIDS).

Chronic Constipation causes 3
• Insulting Natural calls.
• Pain at anus (Fissure, anal stricture,
Growth).
• Bed ridden patients

Chronic Constipation causes 4 (Habitual
Constipation)
• 4) In Elderly alternate constipation &
Diarrhoea or Constipation with P /R
bleeding ---- R / O -- Malignancy of colon
or rectum
• 5) Long term use of Laxatives or Enema(
Loss of Muscle Tone)

Types of stool

Chronic Constipation

Constipation

Constipation –
Takes much time to get sensation

Constipation –
How much I should strain ?

Squatting & Constipation relation?

Chronic Constipation- Treatment
• 1) Treat above said causes & Regular abdominal
massage on empty stomach with warm sesame oil &
fomentation. Regular 45 min walk, Pavanmuktasan,
Naukasan
• 2) Intermittent ayurvedic oil Enemata (Anuvasan
Basti).
Caution
Elderly patient – alternate constipation & Diarrhea,
with P/R bleeding – Rule out Rectal or colonic cancer.

Constipation –Causes & Effects
Habit Effect Effect Final Effect
Suppression of urge
to defecate
Contraction of
External sphincter
& associated
muscles
Absence of Bowel
movement
Constipation
Inadequate fluid &
water intake
Increased intestinal
transit time
Increased
reabsorption of
water
Constipation
Chronic Anxiety Generalized muscle
tension
Decreased
intestinal motility
Constipation
Inadequate physical
exercise
Decreased Muscle
tone
Decreased
Peristalsis
Constipation

Constipation misunderstanding

Congenital Problems
• 1) Post anal dermoid cyst
• 2) Sacro-Coccygeal Teratoma
• 3) Imperforated Anus

1) Post anal dermoid cyst
• Situated behind anus & in front of coccyx
& sacrum.
• May be seen in adults.
• Soft cystic swelling
• Cyst may get infected & sinus may form
• Treatment - Excision

2) Sacro-Coccygeal Teratoma
• Teratoma at sacro-coccygeal region.
• Most common Tumour seen in neonatal baby.
• Firm in consistency
• It is usually seen as a big swelling & may
change into malignancy.
• Treatment - Excision

3) Imperforated Anus
• Common congenital abnormality
• Imperfect fusion of a hind-gut &
lower part of anal canal
(proctodeum)

Anal stenosis
• The whole of anal canal is narrow or
anus is microscopic with a minute
opening
• The patient presents passing of a
meconium with pain
• Treatment - Regular dilatation of anus.

Narrow Anal opening

Ano-Rectal Agenesis
• A blind rectal pouch lies just above the pelvic
floor.
• In the male the fusion is attached to bladder &
often there is a fistula between rectum &
bladder known as rectovesical fistula.
• In females, fistula may be present with
posterior fornix.
• In this variety, sometimes gas or meconium is
present in urine.

Anorectal Agenesis

Recto vesical Fistula

Etymology of Haemorrhoid
• Pile - Pila = ball = Round shape
• Hemorrhoid ---
• Haem = Blood & Orrhos = Oozing

Piles
• Dilated plexus of hemorrhoidal veins in
relation to anal canal
• Inflammation of anal cushion
• (Anal cushion is formed by venules,
arterioles, arterio venule junction,
smooth connecting tissues & mucosa of
anal canal.)

Piles –Causes
• 1) Standing or prolong sitting ( blood has to flow
against gravity )
• 2) Defaecation - The veins passes through mucosa of
anus & rectum .They get constricted if there are hard
stool
• 3) Excessive straining
• 4) Absence of valves or congenital weak veins
• 5) Pregnancy - Due to the pressure effect & hormones
which relaxes muscles of the vein.
• 6) Carcinoma of rectum due to backpressure.
• 7) Portal Hypertension

Classification of Piles – Antomical
Type Site of Piles
Internal
Hemorrhoids
Situated above dentate line & covered with
mucosa
External
Hemorrhoids
situated below dentate line & covered with
skin.
Interno
external
Hemorrhoids
situated above & below dentate line &
covered with mucosa & skin

Classification of Piles – Position
Type of Pile Position
Primary
Piles
situated at --11, 7 & 3 o’clock position
Secondary
Piles
situated at -- 1 o’clock, 2 o’clock

Classification of Piles – Prolapse
Degree Condition of Piles
First Only bleeding but do not come out of anus
Second Protrude during defaecation but goes
automatically inside the anus
Third Protrude out & has to pushed inside manually
Forth Protrude out ,not only during defaecation but
even during coughing, sneezing, laughing &
remains outside .

Piles – Clinical Features
• 1) Painless Bleeding - bleeding after
defecation, which is dropwise or splash in the
pan.
• External piles doesn’t bleed usually but gives
only pain
• 2) Protrusion of Mass 3) Discharge of Mucus
• 4) Itching or Irritation 5) Soiling of under
garments

Piles – P/R Examination
• Internal piles can’t be felt unless they
are secondary infected
• Proctoscopy - Internal piles bulge
into lumen of proctoscope which are
in purple colour

Grades of Piles

Piles Treatment

Piles – Complications
• Pain – when there is secondary infection.
• Thrombosis
• Ulceration
• Suppuration

Piles – Medical Treatment
• Purgatives.
• Sitz bath
• Local -- Xylocaine Jelly if pain.
• Tab Voveron LA – 1 BD.
• Antibiotics --- if infection is suspected
• Laxatives – To avoid straining

Piles – Surgical Treatment
• Lord’s dilatation
• Injection therapy
• Baroon band ligation
• Cryo surgery
• Infra Red coagulation
• Transfix & ligation
• Hemorrhoidectomy
• Ksharsutra therapy

Dry Piles
• (i) Kankayan Guti -- 2 Tab. 3 times a day
• (ii) Triphala Guggulu ---- 2 Tab. 3 times a
day
• (iii) Abhayarishtha -- 4 tablespoon with
equal amount of water 2 times after
meals.

Dry Piles
• (i) Kutaja Ghana vati -- 2 Tab. 3 times a day
• (ii) Arogyavardhini -- 2 Tab. 3 times a day
• (iii) Amrutbhallatakavleha -- 1 tablespoon
each morning
• (iv) Gandharva Haritaki Churna -- 1
tablespoon at bed time with warm water.

Dry Piles – Locally
• (i) Apply Sarjarasa malahar or
Shatadhout ghruta locally
• (ii) Fumigate with Guggulu, Vacha,
Dhoopa, Owa etc.
• (iii) Apply Chukra Taila and advice Sit’z
bath.

Bleeding Piles
• (i) Bolabaddha Rasa -- 2 Tab. 3 times a
day
• (ii) Samasharkara Churna -- 2 Tsf 3 times
a day
• (iii) Triphala Churna -- 2 tablespoon at
bed time with ghee and warm water

Bleeding Piles
• (i) Praval Vati (HP) -- 2 Tab. 3 times a
day
• (ii) Kamaduha Vati (HP)-- 2 Tab. 3
times a day
• (iii) Kutajarishtha --4 tablespoon
with equal amount of water times
after meals.

Bleeding Piles
• (i) Pilex (Himalaya) -- 2 Tab. 3 times a day.
• (ii) Pyroids (B) 2 Tab.-- 3 times a day.
• OR
• (i) Arshonyl (C) --2 Tab. 3 times a day.
• OR
• (i) Nagkeshar Churna – 1 table spoon with
butter and warm water 3 times a day.

Bleeding Piles
• Local Application :-----
• (i) Shatadhouta Ghruta
• (ii) Pilex, Arshonyl ointment.

Bleeding Piles-Regimen
• (i) Use of Suran (only for Dry piles) and
Takra (butter milk) is advisable. If
excessive bleeding, instead of Suran,
take black resins 30 to 40 each day.
• (ii) Old rice, wheat, Takra, Shunth (dry
ginger powder), Padaval etc. are good for
piles.

Bleeding Piles -Regimen
• (iii) Stay away from spicy, hot food
and curd.
• (iv) Sitting on uneven surface, or in
the same position for long, riding a
bike, travelling, forcible bowel
movements are to be avoided.

Fissure in Ano
• Longitudinal ulcer in the lower end
of anal canal
• Mostly due to constipation
• Most painful condition in the anal
region
• Seen in young adults

Fissure –Common site
• In males is 90% at the posterior &
10% at the anterior site
• In females during pregnancy due to
tear of perineum resulting in loose
support to the anterior anus – So
common site is anterior 60% & 40%
at posterior site.

Types of Fissure in Ano
• 1) Primary --- fissure is situated at midline of
anus
• 2) Secondary -- situated other than midline
of anus
• Seen in secondary diseases like ulcerative
colitis, Crohn’s disease, malignancy, syphilis,
diabetes mellitus & trauma.

Fissure in Ano –Clinical features
• 1) Pain -- Remain after defecation constant up
to 4 hrs ( burning or cutting in nature)
• 2) Hard stool -- pellet like
• 3 )Sentinel piles -- Always present in fissure in
ano. They are due to mal union, fibrosis of
fissure & chronicity

Fissure in Ano –Clinical features
• 4 )Bleeding -- Negligible in fissure .Bleeding is
streak like on stool matter on a toilet paper.
Sometimes as a drop.
• 5 )Abscess -- Due to injury to anal gland,
infection results in pus formation.
• 6 ) Itching -- Due to continuous watery
discharge from fissure, perianal area remains
wet .This results in irritation or itching in
perianal region

Fissure in Ano
• On Inspection of Anal region -- fissure is
visible in midline.
• P/R Digital examination – is difficult In
acute condition ,due to pain
• In chronic condition -- fissure is palpable
& tenderness & spasm of sphincter can
be noted

Fissure in Ano – Medical Treatment
• Locally -- Xylocaine jelly for local pain
relief
• Laxatives
• Sitz bath
• NSAIDs ,Antibiotic
• Inferior haemorrhoidale nerve block may
be tried for relief of pain.

Fissure in Ano – Surgical Treatment
• Lord’s Dilatation
• Fissurectomy
• Sphincterectomy

Stretching of Anal canal
• Lords procedure of anal dilatation is the
easiest method to dilate the sphincter of
anal canal under general or spinal
anaesthesia
• Patient in a Lithotomy position
• There may be some faecal incontinence
for a few days

Fissurectomy
• A triangular incision (v shaped) is made
with a surgical knife, starting from anal
margin on each site of the fissure
• Edges of fissure sutured with 2-0 chromic
catgut with interrupted suture
• Complication --- Anal stricture

Anorectal fissure
• (i) Chandrakala Rasa 2 Tab. 3 times a day.
• (ii) Mauktika Kamadudha 1- 2 Tab. 3 times a day.
• (iii) Abhayarishtha 4 tablespoon with equal
amount of water 2 times after meals
• Local Application :
• (i) Shatadhouta Ghruta/ Kailas Jeevan
• (ii) Jatyadi Ghruta/Taila
• It is always better to consult a specialist if no
improvement is noted

Advice for Ano Rectal diseases
• 1) Avoid Constipation
• 2) Avoid Straining in toilet
• 3) Avoid chilly, spicy, non vegetarian
• 4) Avoid prolonged sitting, standing
& walking

Advice for Ano Rectal diseases
• 5) Keep Anorectal part clean & dry. This
area should be washed with diluted anti
septic solution like savlon or KMnO4 (sitz
bath)
• 6) Take a lot of liquids & butter milk.
• 7) Eat fruits like Grapes, Figs & Green
leafy vegetables which will help for easy
evacuation of stools

Fistula - in - Ano
• Fistula = Pipe or Tube
• Abnormal communication of
unhealthy granulation tissue
between anal canal or rectum with
external perianal skin

Fistula - in – Ano –Types
• 1) Internal fistula
• 2) External fistula

Fistula - in – Ano – Causes
• 1)Due to persistent anal gland infection which
results in ano rectal abscess, rupture inside or
outside resulting in fistula
• 2) Tuberculosis
• 3) Ulcerative colitis
• 4) Crohn’s disease
• 5) Carcinoma of Rectum
• 6) Diabetes mellitus

Fistula - in – Ano- Classification 1
• 1) Low anal fistula - Internal
opening below the ano rectal
ring
• 2) High anal fistula - Internal
opening above ano rectal ring

High & Low level Fistula

Fistula - in – Ano- Classification 2
• 1) Sub cutaneous
• 2) Sub mucosal
• 3) Pelvic rectal

Goodsall’s Rule (1900)
• 1) If the external opening is anterior
to an imaginary line within 3.75 cm
from mid point of the anus then -----
• The fistula runs straight (directly)
into the anal canal.

• 2) If the external opening is situated
posterior to that line then -----
• The track usually will curve &
internal opening will be on the
midline posterior of the anal canal (6
o’clock).

• 3) When external opening is anterior
but situated more than 3.75 cm
away from anus, then ---
• Track will curve & end in midline
posterior in anus.

Fistula in Ano
Types of Fistula Goodsoll’s law

Fistula in Ano –Clinical Features
• Persistent, purulent, thick discharge,
which keeps the part, always wet
• Pus discharge stained with blood
• Intermittent pain with relation to
discharge
• Internal opening felt as a buttonhole on
digital examination

Types of Fistula
• External Blind Fistula - External
opening present but internal
opening is absent
• Internal Blind Fistula - Internal
opening present but external
opening is blind or absent.

Examination of Fistula
• Inspection of peri anal region -- External
opening is visible
• Direction of anus is palpable towards anus or
rectum.
• Probing - It is carried out to see weather
internal opening is complete or external
opening is complete.
• Methylene Blue dye is used

Treatment of Fistula in Ano
• In acute stage antibiotic should be given
after pus culture & sensitivity test,
• Warm Sitz’s bath
• Laxative & NSAIDs are given like Tab
Combiflam or Voveron LA 100 mg BD
• Surgical -- Injection therapy or
Fistulotomy or Fistulectomy

Benefits of Ayurvedic Kshar Sutra
• 1) Minimum trauma
• 2) No tissue loss
• 3) No incontinence ( So specially useful in High
level Fistula)
• 4) Cost is less
• 5) It cuts & heals from the base ( Like
Chemical Cautery)
• 6) Very narrow & fine scar

Ksharsutra For Fistula

Benefits of Ayurvedic Kshar Sutra
• 7) No bleeding or minimum bleeding
occurs
• 8) Low quality anesthesia is required
• 9) Minimal hospital stay
• 10) Recurrence rate is very low

Prolapse of Rectum
• Protrusion of a mucus membrane or
wall of rectum outside the anal
verge is known as prolapse of rectum
or Procidentia
• Common in children & old persons

Partial Prolapse
• The prolapse in which
protrusion is less than 5 cm
outside the anal verge is
known as partial or mucosal
prolapse.

Partial Prolapse-Causes
• It may be due to undeveloped sacral curvature
• Constipation.
• Mostly seen after an episode of whooping cough
or after acute attack of diarrhoea
• Loss of fat in ischio-rectal fossa, which support to
Rectum
• Due to delivery trauma or tear of perineum.
• Treatment -- Digital Reposition

Complete Prolapse
• Protrusion of rectum more than 5
cm or rectal wall outside the anal
verge
• Seen in females associated with
uterus prolapse

Complete Prolapse – Causes
• As age advances muscles become weak
due to degeneration & results in
prolapse of rectum
• Straining due to habitual constipation
• Mostly this type of prolapse is associated
with blood & mucus discharge

Complete Prolapse – Treatment
• Thiersch’s wiring
• Rectopexy
• Well’s operation
• Goodsall's ligature

Rectal Prolapse
• (i) Insert prolapsed rectum inside
• (ii) Use Chukra Oil / Mushaka Oil for
lubrication
• (iii) Make a tight bandage with above
said oils over the rectum

Rectal Prolapse

Rectal Prolapse
• Note : Find out the cause, more often is
loose motions . treat the disease
properly.
• (i) Do not force yourself for evacuating
the bowels.
• (ii) Do not suppress natural urges like
Micturition or passing the stools.

Pilonidal Sinus
• Pilus = Hairs & Nidus = Nest
• Nest of hairs into skin in the inflammatory
skin known as Pilonidal Sinus
• Also known as ‘Jeep Bottom Disease –
Because it was more common in Jeep Drivers
at the time of II nd World War.
• Common in hairy person at the age of puberty.

Pilonidal Sinus
• In western countries most
commonly seen in toilet paper users
• Sinus is related to subcutaneous
tissue & rarely reaches to the bone &
it is not related to anus

Pilonidal Sinus
• Sinus has one or more openings
• Typically projecting hairs from its mouth – This
is a cardinal sign of pilonidal sinus.
• Clinical features -- painful swelling, tenderness,
continuous discharge
• High recurrence.
• Sinogram confirms the diagnosis
• Treatment -- excision of sinus with bunch of hairs
• Healing occurs by secondary intension.

Pilonidal Cyst

Stricture of Anus & Rectum
• Congenital --- Narrowing of lumen
occurs at level of anal membrane
• Traumatic -- Injury to rectum during
sphincterectomy
,hemorrhoidectomy, excision of
polyp.

• Inflammation --- which may be due to --
• Tuberculosis
• Ulcer
• Ulcerative colitis
• Crohn’s disease
• syphilitic ulcer
• These causes --- stricture during healing
process of ulcer

• Neoplastic --- Annular & ulcerative
carcinoma
• Miscellaneous --- Persistent internal
sphincter contracture due to
constipation.

Stricture of Anus & Rectum –Treatment
• Surgical treatment is unsatisfactory So
better try to prevent stricture formation
• Patients are advised for -- frequent
digital dilatation or anal dilator, after
anus & rectum operations during healing
process

Condyloma (Genital Warts)
• Causative organism is HPV (Human
Papilloma Virus)
• Transmission is usually sexual who
practices anal intercourse or male
homosexual, Syphilis, Gonorrhea,
AIDS

Condyloma –Clinical features
• The growth looks like cauliflower
• Mass is pedunculated or sessile
• Protrusion of mass
• Located on perianal skin like penis, vulva,
• vagina & cervix
• Diagnosis is confirmed by Biopsy

Condyloma –Clinical features
• Pruritus
• Wetness
• Discomfort
• Treatment –
• Local application of caustic
• Local excision of condylomata

Condyloma lata

Carcinoma of Rectum –
Predisposing Factors
• Smoking
• Alcohol
• Crohn’s disease
• Polyp
• Fistula

CA Rectum – Clinical Features
• Increase in constipation (early
symptom) or Alternate Constipation
& Diarrhoea
• Painless bleeding -- maroon color
(early symptom)
• Sense of incomplete defecation
• Tenesmus

CA Rectum – Clinical Features
• Mucus discharge with stool
• Loss of appetite & weight
• Pain is last symptom
• Abdomen distension due to obstruction
• Metastasis signs are -- Ascites, Jaundice,
Backache, enlarged lymph nodes,
hemoptysis

CA Rectum– Examination
• P/R Examination -- should be done in every case
of PR bleeding
• An indurated growth or ulcer can be felt
• After removing of finger it is stained with blood
• Proctoscopy - Bleeding ulcer or growth may be
visible.
• Colonoscopy
• Biopsy

Rectal Cancer

CA Rectum - Duke’s Classification
• a) Marking ‘A’ - Growth is involved in rectum
& anus
• b) Mark ‘B’ - Growth beyond rectal wall but
lymph nodes aren’t enlarged
• c) Mark ‘C’ - Lymph nodes are enlarged
• C1 – Local & C2 - In course of circulation.
• Treatment -- Permanent Colostomy

Bleeding per rectum-Causes
• Congenital - Rectal polyp
• Traumatic - Injury to rectum or anus
• Fissure in Ano ( Severe pain with
bleeding)
• Bleeding Piles ( Dropwise or splash of
bleeding)
• Fistula in Ano ( Blood with mucus)

• Inflammatory –
• Dysentery
• Crohn’s Disease
• Tuberculine ulcer in intestine

• Neoplastic –
• Tumor of intestine
• Carcinoma of colon or rectum or anus
• Miscellaneous - Piles Prolapse Fistula
• Drugs Group 1) Anti-coagulant 2) Endo
Methacin 3) Chloroquine 4) Aspirin 5) Cortico-
steroids 6) Phenyl Butazone

Bleeding per rectum
• For any kind of per rectal bleeding use
following symptomatic treatment
• Chandrakala Rasa 50 mg. + Praval
Bhasma 50 mg. + Mauktika Bhasma 50
mg. + Amalaki Churna 500 mg. +
Nagkeshar Churna 25 mg. 3 times a day

Pruritus Ani with Discharge -Causes
• Piles
• Condylomata
• Polyps
• Carcinoma of anus
• Any growth
• Fissure
• Fistula

Pruritus Ani with vaginal problems
• Trichomonal vaginitis
• Cervicitis
• Leucorrhoea

Pruritus Ani with worms & Fungus
• Threadworm
• Monilial infection
• Tinea cruris

Pruritus Ani with skin problems
• Allergic dermatitis
• Psoriasis
• Eczema

Pruritus Ani with Metabolic problems
•Obstructive Jaundice
• Diabetes mellitus

Pruritus Ani –Other causes
• Excess or frequent use of laxative
drugs -- causes excessive secretions
• Synthetic or rough inner garments
• Poor hygiene of perianal region.

Anal Itching –Summary
• Itchy skin around anus
• Causes –
• Skin diseases like scabies ,Tinea
• Allegic reactions to under garments
• Uncontrolled DM
• Fissure ,Fistula in ano ,Thread worms
• Liver diseases
• Cancer

Anal Itching –Ayurved Principles
• Krumighna
• Kandughna
• Kaphaghna
• Rakta prasadan

Ano Rectal Pain
• All the anal conditions below dentate line are
painful because supplied by spinal nerve
segment
• Conditions ,above dentate line are painless as
long because they are supplied by
autonomous nervous system
• These painless lesion can become painful
,when they spread beyond rectal wall by
inflammation & infiltration.

Various painful Ano Rectal conditions
Sr.No Condition Cause
1 Continuous Throbbing pain Perianal or Anorectal
abscess
2 Sharp cutting, burning, shooting pain Fissure in Ano
3 Pain is intermittent Chronic sinus or Fistula
4 Painless ulcer Syphilitic
5 Lower Abdomen Pain Obstructive
lesion within the rectum
6 Tenesmus Rectal growth

Perianal haematoma
• (i) Triphala Guggulu 2 Tab. 3 times a day
• (ii) Gokshuradi Guggulu 2 Tab. 3 times a
day
• (iii) Vatavidhvans Rasa 1 Tab. 3 times a
day
• (iv) For local application . Dashang Lepa

Abscess (Peri anal)
• (i) Sukshma Triphala (AYR) 2 Tab. 3 times a day.
• (ii) Gandhak Rasayana 2 Tab. 3 times a day.
• (iii) Septilin 2 Tab. 3 times a day.
• (iv) Triphala Guggulu 2 Tab. 3 times a day.
• (v) Local application : Lepa Goli
• Note : With the treatment, if there is pus in the
absess incision and drainage is a better choice, if
no facility refer to a specialist.

Anal incontinence
• Anal incontinence is defined as loss on control
of defecation act
• Anorectal ring is the important structure to
control defaecation act
• Anorectal ring marks the junction between the
rectum & anal canal
• It is formed by pubo rectalis, highest part of
internal sphincter, longitudinal muscle &
external part of sphincter

Anal incontinence –Causes
• 1) Traumatic to rectum & anal canal
• 2) Surgical procedure of rectum &
anal canal
• 3) Neurological causes
• 4) Malignancy

• 5) Congenital anomalies
• 6) Old age
• 7) Malnutrition
• 8) Rectal prolapse or prolapsed
piles

• 9) Diarrhoea
• 10) Irritable bowel syndrome ( IBS)
• 11) Psychological

Anal incontinence –Treatment
• Temporary incontinence – Reassurance &
perineal exercises to improve the tone of
internal & external sphincter.
• Suturing of the torn sphincter
• Permanent incontinence – inter sphincteric
repair of puborectalis & plication of the
external sphincter

Proctitis
• Inflammation of rectal mucosa with
inflammation of colon & anal canal
• Types –
• Acute or chronic
• non specific or specific

Proctitis –Causes
• Bacillary dysentery
• Amoebic proctitis
• Gonococcal
• Lymphogranuloma inguinale
• Tuberculosis
• Enema - Complication

Proctitis –Clinical Features
• Pain
• Tenesmus
• Mucus & pus discharge
• Frequent urge to pass stool
• Local Tenderness

Proctitis - Investigations
• Proctoscopy
• sigmoidoscopy
• stool culture
• Biopsy

Proctitis

Proctitis
• Treat the root cause
• Antibiotics
• Anti amoebic
• Retention enema of prednisolone
• Tab salazopyrin

Rectal polyp
• Any circumscribed mass of tissue that
arises from mucosa & protrudes into the
lumen of rectum
• Common in children in the first decade
of life
• May appear in adults also
• Rare after 30 years of age

Rectal polyp –Causes
• Congenital
• Inflammatory
• Neoplastic
• Miscellaneous

Rectal polyp –Clinical Features
• Streaks of blood on the stool or sometimes
profuse bleeding
• Protrusion of mass during defecation
• Mucous discharge
• Anaemia due to recurrent bleeding
• Tenesmus
• Usually it is painless but painful if infected

Rectal polyp –Examination
• P/R Examination
• Proctoscopy
• Sigmoidoscopy

Rectal polyp –Treatment
• Excision – polypectomy

Ayurved & Guda Bhransha
( Rectal Prolapse )
• Acute & Chronic
• Concern diseases – Arsha
,Malavrodha,Bhagandar
• Dosha –Vata ,Dhatu – Mansa ,Mala –Purisha
• Srotas – Anna, Purisha,Mutra ,Mansavaha
• Chikitsa – Vatanuloman, Vata shaman,
Deepan,Pachan ,Langhan ,Mansa Rasayan
;Bahya – Snehan, Dhoopan

• Arogyavardhini + Triphala Guggulu – 3 each
BD with Abhayarishta 4 tsf BD with equal
quantity of water --- If Constipation + Erand
haritaki churna 1 tsf HS + If Krumi ,add Kapiladi
vati 3 tab HS
• Externally apply Shatadhauta Ghruta
• Anuvasan Basti – Karanj Tail or Shatavari tail
50 ml
• Dhupan with – Ud ,Dhup,Vekhand,Owa ,Shopa

• If Ajjerna ,Aanah, Aatop – add Praval
panchamrut tab 3 BD with Pippalyadi kadha
or Panchakolasav 4 tsf with equal quantity of
water
• If Gudabhransha is due to Atisar –Give
Sanjeevani tab 3 BD with Kutarishta 4 tsf with
equal quanrity of water

• Rasayan – to improve Mansa Samvanan (
Tone of muscle ) –
• Vishatinduk vati ( Kuchala or nux vomica)
-2 tab after breakfast with Balarishta 4
tsf with equal quantity of water &
Chukra tail Picchu at anal region at night
with Bandage

Ayurved & Parikartik ( Fissure in Ano )
• Types – Vataja, Pittaj
• Associated Diseases –
• Daurbalya
• Karshya
• Pandu
• Gudabhransha
• Atisar
• Bhagandar
• Arsha

Ayurved &Parikartika( Fissure in Ano )
• Dosha – Vata prakop due to ruksha, khara,
sukshma gun ,Pitta prakop due to Ushna
,Tikshna gun
• Dhatu – Rasa Kshay,Rakta dushti ,Mansa
Kshay ; Mala – Purisha
• Chikitsa – Shaman, Vatanuloman, Vata
shaman ,Rakta prasadan, Pitta shaman

Ayurved & Parikartika(Fissure in Ano)
• Chikitsa – Praval pishti vati + Kamdudha – 3
tab each BD with Abhayarishta 4 tsf BD with
equal water
• If severe pain & burning – Tab Triphala
Guggulu + Tab Kaishor Guggulu – 3 tab each
BD & Mauktik bhasma 30 mg + Avipattikar
churna 3 gm HS

Ayurved & Parikartika(Fissure in Ano)
• If very hard stool – Chinchalavan tail 3 tsf BD
,before food
• Externally --- Avagaha sweda with Luke warn
Triphala + Shatavari + Arjun + Yastimadhu
decoction in the morning & Shatavari Tail or
Shatadhaut ghrut Pichu with Bandage or diaper at
night
• Pathya – soft diet ,eating black raisins & dry figs
• Apathya – Dry ,spicy ,irritating food

Bhagandar ( Fistula in Ano )
• Associated diseases – Krumi,
Malavrodha,
Parikartika,Arsha,Kushtha,Vran ,Nadi
vran
• Dosha – Piita dushti ,Kapha prakop
• Dhatu – Rasa or lasika ,Rakta dushti
,Mansa dushti
• Mala – Purisha ,Kleda

• Chikitsa – Malanuloman ,Rakta shodhan
,Vrana shodhan, Vran ropan ,Agni
vardhan, Kapha pitta shaman
• Triphala Guggulu + Arogyavardhini +
Praval pishti + Kamdudha –each 3 BD
with Mahamanjisthadi Kadha 4 tsf with
equal quantity of water

• If only oedema – Upanaha with
Takankhar + wheat dough
• Lasika strav – Upanah + apply Eladi tail or
vran shodhan tail
• If severe pain – Dhupan –with – Ud ,
Dhup, Vekhand ( Acoraus calamus) ,Owa
( Ajwain ) ,Shepa ( fennel)

• Best policy – Tatra Dhanvantariyanam
Adhikaraha – refer to surgeon for Kshar sutra
treatment ( Refer PPT of Ksharsutra by
Prof.Dr.R.R.deshpande on slideshare.com )
• Rasayan – Tab Thayostanin ( Ayurved
Rasashala ,Pune ) 3 in the morning with
Sarivadyasav 4 tsf with equal quantity of
water

• Pathya --- Soft diet ,Local Anorectal Hygiene
• Apathya – Spicy & irritating food ,Synthetic or
tight under garments ,Keeping late at night
,Alcohol ,Tobacco, Smoking,Non Veg food
,Prolonged sitting at one place ,sitting on very
hard surface ,Excess travelling on bike

Arsha ( Piles )
• Types – Shushka ( Dry) ,Raktarsha ( Bleeding
piles )
• Associated Diseases – Malavrodha,
Gudabhransha,Agirna,Agnimadya,Grahani,
Yakrut vicar
• Dosha – Vata ,Kapha
• Dhatu – Rakta dushti,Mansa ; Mala – Purisha

Arsha ( Piles )
• Chikitsa – Vatanuloman ,Rakta shodhan,
Kaphagnha
• Shushkarsha – Tab Arogyavardhini ,Kankayan
guti ,Triphala guggulu – 3 tab each BD with
Abhayarishta 4 tsf with equal quantity of
water
• If Oedema – Apply Sarjaras malam

Arsha ( Piles )
• If Pain – Upanaha with dove of Jwar or
Dhupan with – Dhup,Ud,Vekhand,Owa or
Avagaha sweda with Triphala ,Dashamul
decoction
• Raktarsha – Tab Bolbaddha ras ,Praval pishti
,Kamdudha ras – each 3 tab BD with
Ashokarishta + Kutajarishta - 4 tsf each with
equal quantity water

Raktarsha Arsha ( Piles )
• If severe weakness due to bleeding –
• Mauktik Bhasma 50 mg + Nagkeshar
churna 500 mg + Tapyadi loha vati 2 tab
BD – with Lohasav 4 tsf with equal
quantity of water
• Dhupan is contraindicated

Arsha ( Piles )
• Pathya --- Soft diet ,Local Anorectal Hygiene
• Apathya – Spicy & irritating food ,Synthetic or
tight under garments ,Keeping late at night
Alcohol ,Tobacco, Smoking, Non Veg food
Prolonged sitting at one place ,sitting on very
hard surface ,Excess travelling on bike

Prof. Dr.R.R.Deshpande
• Sharing of Knowledge
• FOR
• Propagating Ayurved

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