Hemorroids
Rectal Prolapse

Video Endoscopic Sequence 1 of 1.

Rectal Prolapse

Rectal prolapse is a condition in which the rectum (the last part of the large intestine before it exits the anus) loses its normal attachments inside the body, allowing it to telescope out through the anus, thereby turning it “inside out”. While this may be uncomfortable, it rarely results in an emergent medical problem. However, it can be quite embarrassing and often has a significant negative impact on patients’ quality of life

As the rectum becomes more prolapsed, the ligaments and muscles may weaken to the point that a large portion of the rectum protrudes from the body through the anus. This stage is called complete prolapse, or full-thickness rectal prolapse, and is the most commonly recognized stage of the condition. Initially, the rectum may protrude and retract depending on the person's movements and activities. However, if the disease goes untreated, the rectum may protrude more frequently or even permanently.

Laparoscopic rectopexy is one of the surgeries used to repair a rectal prolapse. In this surgery, the rectum is restored to its normal position in the pelvis, so that it no longer prolapses (protrudes) through the anus. Usually, stitches are used to secure the rectum, often along with mesh.

Rectal Prolapse

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

All endoscopic images shown in this Atlas contain
video clips.

 

Internal Hemorrhoids

Video Endoscopic Sequence 1 of 5.

Internal Hemorrhoids. Retroflexed view

Hemorrhoids are seen in retroflexed maneuver,
One is ulcerated which caused an intermittent rectal bleeding In (the middle to the three counterclockwise).

 

 

Internal Hemorrhoids


 

.

Internal hemorrhoids

Video Endoscopic Sequence 2 of 5.

Internal hemorrhoids are observed. ulcerated hemorrhoid that has been bleed is observed. About six "clockwise"

internal hemorrhoids is a common cause of gastrointestinal consultations.

Internal hemorrhoids

Video Endoscopic Sequence 3 of 5.

Internal Hemorrhoids.

Through of the metal anoscope and using a video colonoscope this video clip and image is obtained.

 

internal hemorrhoids practicing the method of rubber bands.

Video Endoscopic Sequence 4 of 5.

It proceed to treat internal hemorrhoids practicing the method of rubber bands.

Inserting a viewing instrument (anoscope) into the anus. The hemorrhoid is grasped with an instrument, and a device places two rubber bands around the base of the hemorrhoid. The hemorrhoid then shrinks and dies and, in about a week, falls off.

 

Internal Hemorrhoids.

Video Endoscopic Sequence 5 of 5.

Final Status after of therapy with rubber bands, a hemorrhoid tied with two bands of black color is seen.

 

 

Internal Hemorrhoids.

Internal Hemorrhoids.

The rectum is observed in the retroflexed maneuver.

 

 

Colonoscopic view of internal hemorrhoids.

Video Endoscopic Sequence 1 of 5.

Colonoscopic view of internal hemorrhoids.

Hemorrhoidal disease is a common entity in the general population and in clinical practice. The most commoncause of hematochezia in adults, it remains high in the differential diagnosis of almost any anorectal complaint.

 

Internal Hemorrhoids: colonoscopic view

Video Endoscopic Sequence 2 of 5.

Internal Hemorrhoids: colonoscopic view in retroflexed image.


Enlarged (hypertrophied) papillae is observed Hemorrhoids they are clusters of vascular tissue (eg, arterioles, venules, arteriolar-venular connections), Hemorrhoids have 3 main cushions. These cushions are situated in the left lateral, right posterior, and right anterior areas of the anal canal. Minor tufts can be found between the cushions.

 

image and video clip of internal hemorrhoids.

Video Endoscopic Sequence 3 of 5.

Another image and video clip of internal hemorrhoids.

Although hemorrhoids are very common, their true prevalence is unknown. Their presence may be underestimated due to the large proportion of relatively asymptomatic patients. Conversely, many nonspecific anorectal symptoms can be reflexively, and falsely, attributed to hemorrhoids without the appropriate workup.


 

hemorrhoids

Video Endoscopic Sequence 4 of 5.

This images observed that the hemorrhoids are congested with reddish color, that is the equivalent of the red sign of esophageal varices.

Hemorrhoids are one of the most frequent anorectal disorders encountered in the primary care settings. They are the most common cause of bleeding per rectum and are responsible for considerable patient suffering and disability. With the newer techniques of diagnosis and office-based interventions, most of the symptoms can be effectively controlled.

 

internal hemorrhoids

Video Endoscopic Sequence 5 of 5.

This colonoscopic view of internal hemorrhoids is appreciated using a magnifying colonoscope.

Most clinicians use the grading system proposed by Banov et alin 1985, which classifies internal hemorrhoids by their degree of prolapse into the anal canal. This system both correlateswith symptoms and guides therapeutic approaches.

Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse.

Grade II hemorrhoids may protrude beyond the anal verge with straining or defecating but reduce spontaneously when straining ceases.

Grade III hemorrhoids protrude spontaneously or with straining and require manual reduction.

Grade IV hemorrhoids chronically prolapse and cannot be reduced. They usually contain both internal and external components and may present with acute thrombosis or strangulation.

 

Rubber band ligation

Video Endoscopic Sequence 1 of 3.

Rubber band ligation is the most effective nonoperative(without incision or excision) treatment for internalhemorrhoids.

Rubber Band Ligation - This procedure involves placing a smallrubber band at the base of the internal hemorrhoid. The band cutsoff blood supply to the hemorrhoid, causing it to shrivel up andoff in about four to seven days. We place two rubber bandsfor each hemorrhoid in a basis of one treatment every one week.

Today, nonsurgical methods are an alternative to surgicalones.

Band ligation of internal hemorrhoids is a well-establishedand accepted office procedure.

 

Endoscopic View of Rubber Band Ligation for Internal

Video Endoscopic Sequence 2 of 3.

Endoscopic View of Rubber Band Ligation for Internal Hemorrhoids.

The band causes the hemorrhoid to wither and drop off painlessly. The treatment is usually applied to one hemorrhoid at a time at intervals of 1 weeks or longer. Used only for Internal hemorrhoids.

 

Endoscopic View of Rubber Band Ligation for Internal

Video Endoscopic Sequence 3 of 3.

Retroflexed Image, Endoscopic View of Rubber Band Ligation for Internal Hemorrhoids.

In 1954, Blaisdel invented the first automatic ligator of hemorrhoids, which was modified by Barron in 1962. From that time, the ligation of hemorrhoids is widely used as an alternative method for the treatment of internal symptomatic hemorrhoids and has replaced hemorrhoidectomy.


 

Status Post Rubber Band for Internal Hemorrhoids.

Status Post Rubber Band for Internal Hemorrhoids.

RBL of hemorrhoids is a widely used method for the treatment of symptomatic hemorrhoids. Removal of the hemorrhoidal tissue, development of fibroconnective tissue at the point of the ligation, fixation of the mucosa and correction of the prolapse are achieved with this method.

 

Status Post Rubber Band Ligation for Internal Hemorrhoids.

Video Endoscopic Sequence 1 of 7.

Status Post Rubber Band Ligation for Internal Hemorrhoids.

This 60 year-old lady who two days previously undergone arubber band treatment for internal hemorrhoids, acolonoscopy was performed finding this image, immediatelyafter the colonoscopy a second treatment was carry out.


 

Status Post Rubber Band Ligation for Internal Hemorrhoids

Video Endoscopic Sequence 2 of 7.

Retroflexed image and video clip.

Rubber band ligation is followed by a lower complication rate when performed in a single ligation.

 

Status Post Rubber Band Ligation for Internal Hemorrhoids

Video Endoscopic Sequence 3 of 7.

Rubber band ligation is a procedure in which the hemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the hemorrhoid.

Candidates for this method are patients with 2nd and 3rd degree hemorrhoids, although some authors consider RBL also suitable in appropriately selected cases of advanced hemorrhoidal disease, cases with 4th degree hemorrhoids and permanent prolapse were also treated.

 

Status Post Rubber Band Ligation for Internal Hemorrhoids

Video Endoscopic Sequence 4 of 7.

Endoscopic Image of Rubber Band Ligation for Internal Hemorrhoids.

The Second treatment with band that strangulated the hemorrhoids.

Five minutes after the second band has been applied , it is observed that the hemorrhoid started with necrosis signs, which is the result of the therapeutic success of this procedure.

 

Status Post Rubber Band Ligation for Internal Hemorrhoids

Video Endoscopic Sequence 5 of 7.

Retroflexed image.

It is observed that the first hemorrhoid that was tied has a yellowih image(fibrin) and the second hemorrhoids is with little signs of necrosis.

Highlighting the efficacy and cost containment of hemorrhoidal ligation.

 

Status Post Rubber Band Ligation for Internal Hemorrhoids

Video Endoscopic Sequence 6 of 7.

Rubber band ligation is a useful, safe and successful method for treating symptomatic 2nd and 3rd degree hemorrhoids, which can be applied successfully in selected cases with 4th degree hemorrhoids, but with an increased rate of recurrence and additional treatment requirements. Also,Rubber band ligation seems to be safe in patients with liver cirrhosis and portal hypertension.

 

Status Post Rubber Band Ligation for Internal Hemorrhoids

Video Endoscopic Sequence 7 of 7.

Today, nonsurgical methods are an alternative to surgical ones. They aim at tissue fixation with or without tissue destruction (sclerotherapy, cryotherapy, photocoagulation, BiCAP, laser), or to fixation with tissue excision (rubber band ligation, RBL).

 

Status Post Rubber Band for Internal Hemorrhoids.

Status Post Rubber Band for Internal Hemorrhoids.

Rubber band ligation is the most-used remedy for grade II and grade III hemorrhoids and is the standard to which other methods are compared. A band ligature is passed through an anoscope and placed on the rectal mucosa proximal to the dentate line. The tissue necroses and sloughs off in 1-2 weeks, leaving an ulcer that later fibroses. No anesthesia is required; complications are uncommon and usually benign.

 

Status post rubber band treatment for internal hemorrhoids

Video Endoscopic Sequence 1 of 3.

Status post rubber band treatment for internal hemorrhoids

This 36 year-old female, who 3 years previously undergone 4 rubber bands treatment for internal hemorrhoids, several scar are seen at colonoscopy close to the dentate line.

 

 
Status post rubber band treatment for internal hemorrhoids

Video Endoscopic Sequence 2 of 3.

One scar is observed close to the dentate line.

 

Status post rubber band treatment for internal hemorrhoids

Video Endoscopic Sequence 3 of 3.

Retroflexed image, there are 4 scar.

 

Third-degree hemorrhoids seen in the colonoscopy.

Third-degree hemorrhoids seen in the colonoscopy.

Third degree hemorrhoids prolapse but require "manualreduction".

 

Rubber Band Ligation.

Rubber Band Ligation.

Rubber band ligation as showed in the image, the hemorrhoid has been strangulated.

Necrotizing pelvic sepsis is a rare, but serious, complication of rubber band ligation. The diagnosis is suggested by the triad of severe pain, fever, and urinary retention. It occurs 1-2 weeks after ligation, frequently in immune compromised patients, and requires prompt surgical debridement.

 

Status Post Rubber Band Ligation.

Status Post Rubber Band Ligation.

The hemorrhoid has been strangulated as it can be observed in white color “necrosis”.

Generally the hemorrhoids, after been legated it takes from two to seven days to become white in color, meaning that it had “necrosis”.

 

Status Post Rubber Band Ligation

Status Post Rubber Band Ligation.

Rubber band ligation, as the video clip shows, two
hemorrhoids have been strangulated.

This method is similar to variceal ligation of the esophagus see varices.

 

Status Post Rubber Band Ligation.

Status Post Rubber Band Ligation.

Status post rubber band treatment, the rectum in retroflexed view. Two yellow ulcers are observed, which is the normal process after the hemorrhoids have been fallen out after necrosis.

 

Anal Fissure.

Video Endoscopic Sequence 1 of 2.

Anal Fissure.

An anal fissure is a small split or tear in the thin moist tissue (mucosa) lining the lower rectum (anus).

Anal fissures are very common in infants, but they may occur at any age. The rate of anal fissures drops with age. Fissures are much less common among school-age children than in infants.

In adults, fissures may be caused by passing large, hard stools, or having diarrhea for a long time. Other factors may include:

Decreased blood flow to the area in older adults
Too much tension in the sphincter muscles that control the anus.
Anal fissures are also common in women after childbirth and in persons with Crohn's disease.

 

 

Anal Fissure.

Video Endoscopic Sequence 2 of 2.

Anal Fissure.

Symptoms:

Anal fissures may cause painful bowel movements and bleeding. There may be blood on the outside of the stool or on the toilet paper (or baby wipes) after a bowel movement.

Symptoms may begin suddenly or develop slowly over time.

Other symptoms may include:

A crack in the anal skin that can be seen when the area is stretched slightly (the fissure is almost always in the middle)
Constipation.


 

Anal Fissure.

Anal Fissure.

For more endoscopic details download the video clips by clicking on the endoscopic images, wait to be downloaded complete then press Alt and Enter; thus you can observe the video in full screen.

Initial therapy for an anal fissure is medical in nature, and more than 80% of acute anal fissures resolve without further therapy. The goals of treatment are to relieve the constipation and to break the cycle of hard bowel movement, associated pain, and worsening constipation. Softer bowel movements are easier and less painful for the patient to pass.

First-line medical therapy consists of therapy with stool-bulking agents, such as fiber supplementation and stool softeners. Laxatives are used as needed to maintain regular bowel movements. Mineral oil may be added to facilitate passage of stool without as much stretching or abrasion of the anal mucosa, but it is not recommended for indefinite use. Sitz baths after bowel movements and as needed provide significant symptomatic relief because they relieve some of the painful internal sphincter muscle spasm.

 

Anal fissure Retroflexed Image.

Video Endoscopic Sequence 1 of 2.

Anal fissure Retroflexed Image.

An anal fissure is a small split or tear in the anal mucosa that may cause painful bowel movements and bleeding. There may be blood on the outside of the stool or on the toilet tissue following a bowel movement.

Recurrence rates are in the range of 30-70% if the high-fiber diet is abandoned after the fissure is healed. This range can be reduced to 15-20% if patients remain on a high-fiber diet.

Second-line medical therapy consists of intra-anal application of 0.4% nitroglycerin (NTG; also called glycerol trinitrate) ointment directly to the internal sphincter Nitroglycerin rectal ointment is approved by the US Food and Drug Administration (FDA) for moderate-to-severe pain associated with anal fissures and may be considered when conservative therapies have failed.

 

 

Anal fissure

Video Endoscopic Sequence 2 of 2.

Anal Fissure.

The image and the video clip is displayed using an anoscope.

The 2014 American College of Gastroenterology clinical guideline on the management of benign anorectal disorders makes the following recommendations for anal fissure :

Acute anal fissure - Providers should use nonoperative treatments (eg, sitz baths, psyllium fiber, and bulking agents) as the first step in therapy (strong recommendation, moderate-quality evidence)
Chronic anal fissure - Providers should treat chronic anal fissure with topical pharmacologic agents (eg, calcium channel blockers or nitrates) (strong recommendation, moderate-quality evidence)
Chronic anal fissure - Providers should refer patients who do not respond to conservative or pharmacologic treatment for local injections of botulinum toxin (strong recommendation, low-quality evidence) or internal anal sphincterotomy (strong recommendation, high-quality evidence.

 

 

Anal Fissure.

Anal Fissure.

An anal fissure is a small tear or cut in the skin lining the anus which can cause pain and or bleeding.

Surgical therapy is usually reserved for acute anal fissures that remain symptomatic after 3-4 weeks of medical therapy and for chronic anal fissures.

Intraoperative Details

Sphincter dilatation

This procedure is a controlled anal stretch or dilatation under general anesthetic. It is performed because one of the causative factors for anal fissure is thought to be a tight internal anal sphincter. Stretching the tight sphincter helps correct the underlying abnormality, thus allowing the fissure to heal. The number of fingers used and the amount of time for which the stretch is applied vary among surgeons.

Although the sphincter stretch does provide symptomatic relief from the anal fissure, it is rarely performed today, because of the high complication rate. Impaired continence is observed in 12-27% of patients as a consequence of uncontrolled stretching and subsequent tearing of the internal and external sphincter.


 

Endoscopic Image of Anal Fissure

Video Endoscopic Sequence 1 of 4.

Endoscopic Image of Anal Fissure

Anal fissure Retroflexed Image.

Intraoperative Details: Lateral internal sphincterotomy

Lateral internal sphincterotomy is the current surgical procedure of choice for anal fissure. The procedure can be performed with the patient under general or spinal anesthesia. (Local anesthesia may even be used in the cooperative patient, though it is not always recommended). The purpose of the operation is to cut the hypertrophied internal sphincter, thereby releasing tension and allowing the fissure to heal.

When first described, sphincterotomy was performed in the posterior midline at the site of the fissure, with or without a fissurectomy. However, the incision for the sphincterotomy usually did not heal, for exactly the same reason that the fissure did not heal. Currently, sphincterotomies are normally performed in the lateral quadrants (right or left, depending on the comfort or handedness of the surgeon). In a properly performed lateral internal sphincterotomy, only the internal sphincter is cut; the external sphincter is not cut and must not be injured.

The sphincterotomy can be performed in either an open or a closed manner, as described below.

 


Anal fissure Retroflexed Image.

Video Endoscopic Sequence 2 of 4.

Anal fissure Retroflexed Image.

In a closed sphincterotomy, a No. 11 blade is inserted sideways into the intersphincteric groove laterally. It is then rotated medially and drawn out to cut the internal sphincter. Care is taken not to cut the anal mucosa, because doing so could result in a fistula. After the knife is removed, the anal mucosa overlying the sphincterotomy is palpated, and a gap in the internal sphincter can be felt through it. The sphincterotomy is extended into the anal canal for a distance equal to the length of the anal fissure.

In an open sphincterotomy, a 0.5- to 1-cm incision is made in the intersphincteric plane. The internal sphincter is then looped on a right angle and brought up into the incision. The internal sphincter is then cut under direct visualization. The two ends are allowed to fall back after being cut. A gap can then be palpated in the internal sphincter through the anal mucosa, as in the closed technique. The incision can be closed or left open to heal.

When treating a chronic anal fissure, the surgeon may elect to perform a fissurectomy in conjunction with the lateral sphincterotomy. In such cases, care must be taken not to include a piece of the internal sphincter with the excision. More simply, instead of excising the fissure along with the sphincterotomy and worrying whether it will heal, the surgeon can excise the hypertrophied papillae and the skin tag and leave the fissure to heal on its own.

Sometimes, long-standing chronic fissures do not heal, even with an adequate sphincterotomy, and an advancement flap must be performed to cover the defect in the mucosa. This can be performed either at the time of the sphincterotomy if the surgeon does not think that the fissure will, heal or as a second procedure if the fissure does not heal.


Anal fissure Retroflexed Image.

Video Endoscopic Sequence 3 of 4.

Anal fissure Retroflexed Image.

 

Anal fissure Retroflexed Image.

Video Endoscopic Sequence 4 of 4.

Anal fissure Retroflexed Image.

Magnifying Image

 

Anal fissure Retroflexed Image.

Enlarged (hypertrophied) papillae of the anus.

In addition to the hypertrofied papillae, some internal hemorrhoids are observed, through the image in retroflexed view.

Reactive hyperplastic process of stromal connective tissue, either in isolation or secondary to nearby infectious/inflammatory process or mass lesion Analogous to cutaneous skin tags.

Clinical features:

Ranges from subtle swelling at base of anal column to mass protruding into anal canal May be associated with or thought to be hemorrhoids May be adjacent to inflammation, abscess, tumor Tend to enlarge over time May be asymptomatic or associated with pain, discharge, itching, especially if longstanding If pathology is isolated to hypertrophied papillae, resection is curative; otherwise, underlying pathology must be treated to relieve symptoms Similarly to hemorrhoids, histopathologic evaluation is necessary to exclude accompanying lesions, such as low or high grade squamous intraepith Ranges from subtle swelling at base of anal column to mass protruding into anal canal May be associated with or thought to be hemorrhoids May be adjacent to inflammation, abscess, tumor Tend to enlarge over time May be asymptomatic or associated with pain, discharge, itching, especially if longstanding If pathology is isolated to hypertrophied papillae, resection is curative; otherwise, underlying pathology must be treated to relieve symptoms Similarly to hemorrhoids, histopathologic evaluation is necessary to exclude accompanying lesions, such as low or high grade squamous intraepithelial lesions, invasive squamous cell carcinoma, rectal carcinoma, neuroendocrine tumors, melanoma, lymphoma, inflammatory bowel disease, non-specific granulomas, Herpes Simplex Virus infection, syphilis.

 

Peri Anal Tuberculosis.

Peri Anal Tuberculosis.

Cutaneous manifestations of tuberculosis are exceptional. In patients with protracted peri-anal ulceration, a biopsy should be performed that will show a typical tuberculoid granuloma. The most frequently encountered anorectal tuberculous lesions are suppurations and fistulae. The main differential diagnosis is Crohn's disease with anorectal manifestations.

 

Condyloma Acuminatum.

Condyloma Acuminatum.

Cauliflower-like projections.

Extensive perianal condyloma acuminata. This condition is generally caused by infection with human papillomavirus. Condylomata can reach substantial size, and multiple lesions are common. If one lesion is present, a complete genital and anorectal examination is indicated to detect additional growths.

Perianal fistula.

Perianal fistula.

A perianal fistula, almost always the result of a previous abscess, is a small passage connecting the anal gland from which the abscess arose to the skin where the abscess was drained.

 

Skin Tabs/Tags

Mucocutaneous folds

Mucocutaneous folds are seen above and fistulous tract
below.

Skin Tabs/Tags

Anal skin tabs/tags are the shapeless lumps and flaps of skin or flesh found at the anal verge. Anal skin tags are an extremely common condition and are frequently associated with other anorectal problems.

Anal skin tags are usually the result of a prior anorectal insult or injury. An acute swelling of an external hemorrhoid, if left untreated, frequently leaves behind a skin tab - also referred to as a hemorrhoidal tab. The skin tab's blood supply from the hemorrhoidal artery above may then give rise to the development of an even larger hemorrhoid. Swollen skin edges as a result of prior rectal surgery may also develop into skin tabs.

A sentinel tag is that skin tab which is situated at the inferior border of an infection or injury, as if it is watching or guarding over. A sentry or sentinel is one that keeps guard - thus the name. Anal fissures and fistula are often associated with secondary changes, which may include a sentinel tag. The proximal end of a fissure or fistula may contain granulation tissue that extrudes, beginning the formation of a sentinel tag.

 

 

Internal Hemorrhoids.

Video Endoscopic Sequence 1 of 2.

Internal Hemorrhoids.

In the video clip you can observe the colonoscope in retroflexed maneuvering, passing across to the anus observing the colonoscopist.

 

Colonoscopy

Video Endoscopic Sequence 2 of 2.

The colonoscopist (myself) is observing the colonoscope that has been removed by this route from the rectun and anus in retroflexed maneuver.

 

Status after rubber band ligation of internal hemorrhoid.

Status after rubber band ligation of internal hemorrhoid.

The rubbers bands have strangulated the hemorrhoid, and ulcerated the mucosa, as a result of the treatment, which is normal. The complete cure of this status can be expected within average of 3 weeks for each hemorrhoid. You ca get treatment by this method as an outpatient, one a weekly basis; that means one treatment each week This treatment is exclusive for internal hemorrhoids. 

 

Video Endoscopic Sequence 1 of 2.

Colonoscopic view of internal hemorrhoids, a status of
after rubber band ligation of internal hemorrhoid is seen.

 

Video Endoscopic Sequence 2 of 2.

Same case as above. Retroflexed image.

 

Hypertrophied Papillae.

Hypertrophied Papillae.

Large Anal hypertrophied papillae that introduced into the rectum.
The presence of Hypertrophied anal papillae and fibrous anal polyps are often ignored in the proctology practice. But the experience is that they tend to produce minor but disturbing symptoms. Removal of hypertrophied anal papillae and fibrous polyps should be carried out as a routine during surgical treatment of anal fissure. This would add to effectiveness and completeness of the procedure.

Hypertrophied anal papillae and fibrous anal polyps are frequently found in association with chronic fissure in ano. Usually, no specific attention is given to them and they are considered normal findings. The present prospective study was aimed at determining whether removal of hypertrophied anal papillae and fibrous anal polyps while dealing with chronic fissure in ano confers long-term benefit to patients.

Removal of hypertrophied anal papillae and fibrous anal polyps increases patient satisfaction after anal fissure.

 

 

Prolapsed Hemorrhoid

Video Endoscopic Sequence 1 of 4.

Prolapsed Hemorrhoid

Stage III - Internal hemorrhoids that bleed and prolapse with straining and require manual effort for replacement into the anal canal.

 

Internal hemorrhoid that Prolapsed

Video Endoscopic Sequence 2 of 4.

Stage III - Internal hemorrhoid that Prolapsed internalhemorrhoids extend into the anal canal or through the anus,outside the anal sphincter; with these, pain usually ensues.

(If the internal hemorrhoid pushes out of the anal opening, thishemorrhoid is called a prolapsed hemorrhoid).

Third degree hemorrhoids prolapse but require "manualreduction".

 

Prolapsed Hemorrhoid

Video Endoscopic Sequence 3 of 4.

Protrusion can occur with both internal and external
varicosities; while some may regress spontaneously, others
may require manual replacement. Other symptoms may
include steady aching in the affected area, non-severe pain,
soreness, discomfort, burning, swelling, mild inflam-mation,
mucous discharge, and seepage.

 

Prolapsed Hemorrhoid

Video Endoscopic Sequence 4 of 4.

Retroflexed image.

Fistula-in-ano

Fistula-in-ano

A fistula-in-ano is a hollow tract lined with granulation tissue connecting a primary opening inside the anal canal t a secondary opening in the perianal skin. Secondary tracts may be multiple and from the same primary opening.

Fistula-in-ano is nearly always caused by a previous anorectal abscess. Anal canal glands situated at the dentate line afford a path for infecting organisms to reach the intramuscular spaces.

Other fistulae develop secondary to trauma, Crohn disease, anal fissures, carcinoma, radiation therapy.

 

Fistula-in-ano

Pathophysiology

The cryptoglandular hypothesis states that an infection begins in the anal gland and progresses into the muscular wall of the anal sphincters to cause an anorectal abscess. Following surgical or spontaneous drainage in the perianal skin, occasionally a granulation tissue–lined tract is left behind, causing recurrent symptoms. Multiple series have shown that the formation of a fistula tract following anorectal abscess occurs in 7-40% of cases.

Physical examination findings remain the mainstay of diagnosis. The examiner should observe the entire perineum, looking for an external opening that appears as an open sinus or elevation of granulation tissue. Spontaneous discharge via the external opening may be apparent or expressible upon digital rectal examination.

 

 

 

 

Fistula-in-ano

Fistula-in-ano

Digital rectal examination may reveal a fibrous tract or cord beneath the skin. It also helps delineate any further acute inflammation that is not yet drained. Lateral or posterior induration suggests deep postanal or ischiorectal extension.

The examiner should determine the relationship between the anorectal ring and the position of the tract before the patient is relaxed by anesthesia. The sphincter tone and voluntary squeeze pressures should be assessed before any surgical intervention to delineate whether preoperative manometry is indicated. Anoscopy is usually required to identify the internal opening.

 

Acute Trombosed hemorrhoids

Sequence 1 of 2.

Acute Trombosed hemorrhoids

This is the case of a 62 year-old male that during 12 years have been suffering from internal hemorrhoids grade III hemorrhoids protrude spontaneously and require manual reduction but never seek medical help, suddenly had an acute trombosed internal and external hemorrhoids .

There are two hemorrhoids that are trombosed one isexternal and one is internal both are trombosed containboth internal and external components with acutethrombosis and strangulation

Are hemorrhoids that have clotted on the inside of the anus(a ‘thrombus’). These clots form in the veins of the rectum justunder the skin. External hemorrhoids can be seen and/or felt.Sometimes they are soft. Other times they are hard.

 

Acute Trombosed hemorrhoids

Sequence 2 of 2.

Acute Trombosed hemorrhoids

Internal hemorrhoids drain through the superior rectal vein into the portal system. External hemorrhoids drain through the inferior rectal vein into the inferior vena cava. Rich anastomoses exist between these 2 and the middle rectal vein, connecting the portal and systemic circulations.

 

 

Fistula in Ano

Sequence 1 of 7.

Fistula in Ano

Fistula-In-Ano: External opening of fistulus tract is apparent inphoto above. Proximal opening would be at level of crypts,within the anal canal. Fistulas are frequently associated withperirectal abscesses, though none are present in this case.

Fistula in Ano

Sequence 2 of 7.

Fistula in Ano

A fistula-in-ano is an abnormal tract or cavity with an external opening in the perianal area that is communicating with the rectum or anal canal by an identifiable internal opening. Most fistulas are thought to arise as a result of cryptoglandular infection with resultant perirectal abscess. The abscess represents the acute inflammatory event, whereas the fistula is representative of the chronic process. Symptoms generally affect quality of life significantly, and they range from minor discomfort and drainage with resultant hygienic problems to sepsis. The treatment of fistula-in-ano remains challenging. Surgery is the treatment of option with the goals of draining infection, eradicating the fistulous tract, and avoiding persistent or recurrent disease while preserving anal sphincter function.

Fistula in Ano

Sequence 3 of 7.

Fistula in Ano

A fistula-in-ano is a hollow tract lined with granulation tissue, connecting a primary opening inside the anal canal to a secondary opening in the perianal skin. Secondary tracts may be multiple and can extend from the same primary opening

Fistula in Ano

Sequence 4 of 7.

Fistula in Ano

The true prevalence of fistula-in-ano is unknown. The incidence of a fistula-in-ano developing from an anal abscess ranges from 26-38%.

Fistula in Ano

Sequence 5 of 7.

Fistula in Ano

Treatment

Fistula-in-ano is treated surgically. No definitive medical therapy is available for this condition; however, long-term antibiotic prophylaxis and infliximab may have a role in recurrent fistulas in patients with Crohn disease.

Fistula in Ano

Sequence 6 of 7.

Fistula in Ano

Fistula in Ano

Sequence 7 of 7.


An anal fistula usually lasts until it is surgically removed. The fistula tract must be opened along with the source of the infection. Usually, tissue around the external opening and the internal opening is excised along with a small margin of tissue lining the tract, called a fistulotomy. Excision of the complete tract is called a fistulectomy.

 

 

Ulcerated Internal Hemorrhoid

Video Endoscopic Sequence 1 of 4.

Ulcerated Internal Hemorrhoid

This is the case of a 79 year-old male, who had several episodes of hematemesis, the hemoglobin drop until 5.9 Gr./dl, the colonoscopy was negative.

 

Endoscopic Image of Ulcerated Internal Hemorrhoid

Video Endoscopic Sequence 2 of 4.

Endoscopic Image of Ulcerated Internal Hemorrhoid

 

Video Endoscopic Image of Ulcerated Internal Hemorrhoid

Video Endoscopic Sequence 3 of 4.

Video Endoscopic Image of Ulcerated Internal Hemorrhoid

 

Video clip of Ulcerated Internal Hemorroid.

Video Endoscopic Sequence 4 of 4.

Video clip of Ulcerated Internal Hemorrhoid.

 

Hypertrophied anal Papillae

Video Endoscopic Sequence 1 of 2.

Hypertrophied anal Papillae

Hypertrophied anal papillae and fibrous anal polyps are frequently found in association with chronic fissure in ano.

Hypertrophied anal papillae and fibrous anal polyps are important anal pathologies associated with chronic anal fissure and are responsible for symptoms like pruritus, a pricking sensation, heaviness, etc. Their removal should be made an essential part of treatment of chronic fissures in ano. Persistence of these structures leaves behind a sense of incomplete treatment and thereby reducing the overall satisfaction on the part of the patient. radio frequency procedures have been found useful in successfully eradicating these concomitant pathologies of chronic fissure in ano. This procedure should be given a fair chance to prove its utility and long-term efficacy.

Hypertrophied anal Papilla

Secuencia Video Endoscópica 2 de 2.

Hypertrophied anal Papillae

Three Hypertrophied anal Papillae and internal hemorrhoids are observed

 

 

 

 

 

 

 

 

 

 

 

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