Anal + Perianal Disease

Question 1

what are haemorrhoids

Answer 1

abnormal swelling/enlargement of anal vascular cushions

Question 2

what is the function of the anal vascular cushions?

how many are there?

Answer 2

they assist the anal sphincter in maintaining continence

- 3

Question 3

how are heamorrhoids classified

Answer 3

according to size:
1st Degree: remain in rectum
2nd Degree: prolapse through anus on defecation but spontaneously reduce
3rd Degree: prolapse through anus on defecation and require digital reduction
4th Degree: remain persistently prolapsed

Question 4

risk factors for haemorrhoids

Answer 4

excessive straining (from chronic constipation)
increasing age
raised intra-abdominal pressure (e.g. pregnancy, chronic cough, ascites)

Question 5

presentation of haemorrhoids

Answer 5

painless bright red PR bleeding

• post defecation
• on surface of stool, not mixed in

itch, rectal fullness, soiling due to impaired continence

Question 6

presentation of a thrombosed prolapsed haemorrhoid

Answer 6

purple/blue, oedematous, tense, tender perianal mass

Question 7

what investigation confirms haemorrhoids

Answer 7

proctoscopy

Question 8

management of haemorrhoids

Answer 8

lifestyle advice: increase daily fibre + fluid intake to avoid constipation
laxatives + topical lignocaine for symptom relief
symptomatic 1st/2nd degree haemorrhoids can be treated with rubber band ligation
3rd/4th degree haemorrhoids may require haemorrhoidectomy

Question 9

what is pilondial sinus disease

Answer 9

formation of a sinus in the inter-gluteal cleft

- due to inflammation + obstruction of hair follicle – pit + cavity formation

Question 10

who gets pilondial sinus disease

Answer 10

caucasian males with course dark body hair
most commonly 16-30 years old
increased risk in those who sit for prolonged periods e.g. lorry drivers / office workers

Question 11

presentation of pilondial sinus disease

Answer 11

intermittent, red painful, swollen mass in sacrococcygeal region
- commonly purulent discharge

Question 12

non-surgical management of pilondial sinus disease

Answer 12

shaving of the affected region

plucking the sinus free of hair that is embedded

Question 13

surgical management of pilondial sinus disease

Answer 13

abscesses: incision + drainage and washout is required

chronic disease: removal of sinus tract

Question 14

what is a perianal fistula

Answer 14

abnormal connection between anal canal + perianal skin

Question 15

what are the majority of perianal fistulas caused by

Answer 15

a perianal abscess

Question 16

risk factors for a perianal fistula

Answer 16

IBD - Crohns or UC
Systemic disease - TB, HIV, Diabetes
Trauma to anal region

Question 17

presentation of perianal fistula

Answer 17

either:

• recurrent abscesses
• discharge onto perineum

Question 18

imaging used to visulise a perianal fistula

Answer 18

proctoscopy

- MRI used in complex fistulas

Question 19

what system is used to classify perianal fistulas

Answer 19

Park’s classification system

Question 20

most common type of perianal fistula

Answer 20

inter-sphincteric fistula

Question 21

surgical options for perianal fistulas

Answer 21

• fistulotomy

- placement of a seton to bring together + close the tract

Question 22

what is an anorectal abscess

Answer 22

collection of pus in the anal-rectal region

Question 23

what causes formation of an anorectal abscess

Answer 23

plugging of anal ducts resulting in fluid stasis + infection

Question 24

infective organisms in an anorectal abscess

Answer 24

E.Coli

Enterococcus

Question 25

presentation of an anorectal abscess

Answer 25

pain in the perianal region which is exacerbated by sitting down

Question 26

what is found on examination of an anorectal abscess

Answer 26

an erythematous, fluctuant, tender perianal mass

Question 27

management of an anorectal abscess

Answer 27

antibiotics + analgesia surgical incision + drainage under GA proctoscopy post drainage to look for any perianal fistulae

Question 28

what is an anal fissure

Answer 28

tear in the mucosal lining of the anal canal | - most commonly due to trauma from defecation of a hard stool

Question 29

how long does an anal fissure need to be present to be classified as - acute - chronic

Answer 29

``` acute = < 6 weeks chronic = > 6 weeks ```

Question 30

presentation of an anal fissure

Answer 30

intense pain post defecation PR bleeding - bright red on wiping itch post defecation

Question 31

where are most anal fissures located

Answer 31

posterior midline

Question 32

medical management of an anal fissure

Answer 32

increase fibre + fluid intake stool softening laxatives topical lidocaine GTN/Diltiazem cream -- increases blood flow + relaxes anal sphincter, decreases pain + promotes healing

Question 33

surgical management of an anal fissure

Answer 33

reserved for chronic fissure where medial management has failed to resolve symptoms: - botox injections - lateral sphincterectomy

Question 34

difference between a - partial thickness rectal prolapse - full thickness rectal prolapse

Answer 34

partial thickness - rectal mucosa protrudes out of anus | full thickness - rectal wall protrudes out of anus

Question 35

risk factors for rectal prolapse

Answer 35

``` increasing age female multiple deliveries straining anorexia ```

Question 36

presentation of a rectal prolapse

Answer 36

rectal mucus discharge faecal incontinence PR bleeding - full thickness prolapses begin internally and may present with rectal fullness + tenesmus

Question 37

investigation of a rectal prolapse

Answer 37

PR - weakened anal sphincter | Ask patient to strain

Question 38

definitive management of rectal prolapse

Answer 38

surgical repair

Question 39

what are the majority of anal cancers

Answer 39

squamous cell carcinomas arising below the dentate line

Question 40

anal cancer risk factors

Answer 40

``` HPV infection (HPV 16,18) HIV Smoking Crohns disease Immunosuppression ```

Question 41

symptoms of anal cancer

Answer 41

``` rectal pain PR bleeding anal discharge itch palpable mass ```

Question 42

investigation of anal cancer

Answer 42

PR proctoscopy examination under anaesthetic (EUA)

Question 43

management of anal cancer

Answer 43

chemo-radiotherapy | abdominoperineal resection for advanced disease