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anal and perianal disorders Flashcards

1
Q

how are anal fissures diagnosed?

A

direct visualisation
tear in skin

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2
Q

which age are fissures most common

A

common across lifetime - more common in 20s-40s

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3
Q

what can cause anal fissures?

A
  • Tearing from passage of hard stools  constipation
  • Anal trauma – sex, surgery
  • Drugs – chemo, opioids, nicorandil (vasodilator  used for angina)
  • Secondary: IBD, STIs
  • Dermatology: psoriasis, eczema, pruritis ani)
  • Pregnancy/ childbirth
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4
Q

what are the symptoms of anal fissures?

A

localised pain on defection – sharp, can be persistent, tearing sensation
- Bleeding: small amount of fresh blood on wiping

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5
Q

what types of management is used for anal fissures?

A
  • Lifestyle: keep stools soft and easy to pass (more fibre, water). Anal hygiene, avoid straining or stool withholding
  • Analgesia: paracetamol ± NSAID, warm bath, avoid opioids (causing constipation)
  • Topical agents: short course of 5% lidocaine ointment can be applied prior to defecation. GTN ointment can be applied BD  headache side effects
  • Surgical:
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6
Q

what are the surgical managements of anal fissures?

A

: most commonly lateral internal sphincterotomy, botox, anal advancement flap

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7
Q

what are haemorrhoids?

A

Abnormally swollen vascular cushions that are located in the anal canal.

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8
Q

when is it most common to get haemorrhoids across lifetime?

A

about 11% in general population with equal sex prevalence and peak between 45-65

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9
Q

what are internal haemorrhoids?

A

located proximal to dentate line

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10
Q

what are external haemorrhoids?

A

distal to dentate line

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11
Q

describe a grade 1 internal haemorrhoid

A
  • Grade1: no prolapse, prominent blood vessels
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12
Q

describe a grade 2 internal haemorrhoid

A
  • Grade2: prolapse upon bearing down but spontaneous reduction
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13
Q

describe a grade 3 internal haemorrhoid

A
  • Grade 3: prolapse upon bearing down requiring manual reduction
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14
Q

describe a grade 4 internal haemorrhoid

A
  • Grade 4: prolapse with inability to be manually reduced
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15
Q

what is the dentate line?

A

divides upper 2/3 of anal canal with lower 1/3

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16
Q

what type of cells are the upper 2/3 of rectum made up of?

A

rectal columnar epithelium

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17
Q

what is the histology of lower 1/3 of rectum?

A

stratified squamous epithelium

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18
Q

why do haemorrhoids become so itchy?

A
  • Lower: stratified squamous epithelium  highly innervated hence highly itchy
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19
Q

what is the aetiology of haemorrhoids??

A

Aetiology: symptomatic haemorrhoids thought to develop with supporting tissue with anal cushions deteriorate
- Deterioration in connective tissue
- Increases internal anal sphincter tone
- Dilation of arteriovenous anastomoses within anal cushions
- Dilation of veins within the haemorrhoidal venous plexus

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20
Q

what are RF of haemorrhoids?

A

constipation and prolonged straining
- Diarrhoea, pregnancy, increased age, prolonged sitting, anticoag use and pelvic tumours

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21
Q

what symptoms are seen with haemorrhoids?

A
  • Perianal irritation
  • Bright red rectal bleeding
  • Faecal incontinence: often mild due to prolapse of haemorrhoids and subsequent leakage
  • Mucous discharge: due to internal haemorrhoids covered with columunar epithelium
  • Fullness in perinanal area
  • Pain: overt pain is uncommon unless there is strangulated haemorrhoid or thrombrosis of haemorrhoid
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22
Q

what would a normal DRE examination show with haemorrhoids?

A

non -prolapsed internal haemorrhoids

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23
Q

how would prolapsed haemorrhoids present O/E?

A

: blue ish, bulging lesion on straining

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24
Q

how would external haemorrhoids present O/E?

A

blue ish bulging lesion

25
Q

how would thrombosed haemorrhoids present?

A

if acute it will be very painful, purplish, oedematous perianal mass

26
Q

how would you non medicinally manage haemorrhoids?

A
  • Healthy lifestyle: sufficient water intake, high fibre to prevent constipation, undertaking physical activity
  • Toilet training: adopt correct positioning during defaecation, avoid straining and prolonged periods on toilet
  • Avoid medications causing constipation
27
Q

how would you pharmacologically manage haemorrhoids?

A
  • Laxatives: may help reduce constipation and reduce bleeding
  • Analgesia: NSAIDS and non-opioid therapies
  • Topical agents: anaesthetic and steroids
  • Venoactive agents: phelbotonics  increase venous tone and reduce bleeding and help with other perianal symptoms such as irritation (flavonoids and calcium dobesilate)
  • Antispasmodics: reduce anal sphincter spasms that may cause perianal symptoms  mainly used in those with anal fissures
28
Q

what are some of the surgical options for haemorrhoids?

A

rubber ligation
sclerotherapy
infrared coagulation
haemorrhoidectomy

29
Q

describe rubber band ligation

A

rubber band at base of haemorrhoid to stop blood flow (grade 1-3 internal)

30
Q

what is sclerotherapy?

A

injection of sclerosant agent into internal haemorrhoid  inflame reaction to destroy submucosal tissue (grade I-II internal haemorrhoid)

31
Q

how is infrared coagulation used within haemorrhoid surgical management?

A
  • Infrared coagulation: infrared light direct to haemorrhoid tissue (grade I – II)
32
Q

what is a haemorrhoidectomy?

A

surgical removing haemorrhoids

33
Q

what are complications of haemorrhoidectomy?

A

complications can include bleeding, faecal incontinence and anal stricture

34
Q

what are risk factors for perianal abscesses?

A

fistula – in- ano
- IBD, DM and immunosuppression

35
Q

what are symptoms of perianal abscesses?

A

Symptoms: typically pain and swelling in peri-anal region
- Sepsis features
- Malaise

36
Q

what are signs of perinanal abscesses?

A

Signs:
- Fluctuant, tender perianal swelling
- Pus discharge
- Erythema
- Fever

37
Q

what is the management of perianal abscesses?

A

Management: incision and drainage  cut into abscess and drain pai and packed with gauze like material (prevents cavity closing over and pus reaccumulating

38
Q

what is fistual- in-ano?

A

fistula are tracts that form between blocked internal gland and skin

39
Q

how would a fistula-in-ano present?

A
  • Presents with pain, discharge, skin irritation and can have bleeding
  • Usually follow abscesses in Chrons, diverticulitis, hidradenitis supprartive (HS), TB< HIV, post-colorectal surgery
40
Q

what are the surgical options of fistula- in-ano options?

A

setons
advancement flap procedure
LIFT
endoscopic ablation
fibrin glue
bioprosthetic plug

41
Q

what do setons do?

A

: surgical thread to help drain sndf heal and progressively tighter ones to slowly cut through fistula in ano

42
Q

what is an advancement flpa procedure?

A

cutting fistula and covering hole with flap
of tissue from inside rectum

43
Q

what LIFT with fistula-in-ano surgery?

A

cut made above fistula and sphincter muscles pulled apart – fistula sealed at both ends

44
Q

what is endoscopic ablation within fistula - in ano?

A
  • Endoscopic ablation: tiny endoscope inserted into fistula and electrode passed through to seal (similar to laser surgery)
45
Q

how does a bioprosthetic plug work?

A

made from animal tissue and blocks internal opening of fistula

46
Q

what is hidradentitis suppurativa also known as?

A

acne inversus

47
Q

what is hidradenitis suppurative (HS)?

A
  • Chronic inflammatory skin conditions with lesions including deep seated nodules and abscesses, draining tracts and fibrotic scars
48
Q

what would an unexplained anal mass or unexplained anal ulceration indicate?

A

anal cancer

49
Q

what is proctalgia fugax?

A

a benign anal pain syndrome

50
Q

what is the aetiology of proctalgia fugax?

A

potentially due to spasm of muscles, could be anal sphincter or pelvic floor muscles

51
Q

what are symptoms of proctalgia fugax?

A

recurrent severe cramping pain, usually at night
- Attacks are so rare so pain management/ drug therapies are not beneficial
- Physio can help and re train muscles

52
Q

what is pruiritis ani?

A

bum itchiness

53
Q

who is more affected in pruritis ani?

A

men more than women
mainly aged 40-60

54
Q

what is the aetiology of pruiritis ani? ,

A
  • 50% are caused by dermatological cause: psoriasis, dermatitis, skin tags, lichen sclerosus ( rare skin disease causing itchy and painful patches of thin, white, wrinkled-looking skin)
  • Parasites: threadworm (paeds/ people around kids), scabies, viral, bacterial, fungal infections including STIs
  • Anal/ colerectal cancer, piles, fissures, fistulas, incontinence, chronic diarrhoea
  • DM, anaemia, leukaemias, thyroid problems, liver disease
  • Medications: steroids, colchicine, Abx, immunosuppressants
55
Q

what is proctitis?

A

: pain and inflammation of the last 6in of rectum

56
Q

what are symptoms of proctitis?

A

faecal urgency, diarrhoea, constipation, tenesmus (needing to poo but can not), mucus on stool, PR bleeding, pus PR

57
Q

what are the RF of proctitis?

A

: in those practicing receptive anal intercourse
- either result of IBD or infections including STI

58
Q
A

GI (12 decks)

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