Anal Problems

Question 1

What is an Anal Fissure?

Answer 1

Longitudinal or elliptical tears of the squamous lining of the distal anal canal.

Question 2

Where does a fissure occur?

Answer 2

Below the level of the dentate line

Question 3

How does an anal fissure present?

Answer 3

Painful on defaecation- tearing sensation

PR bleeding on stool or toilet paper

Question 4

What would you see next to the lesion with an anal fissure?

Answer 4

Adenomatous skin tag

Question 5

What is another name for the adenomatous skin tag?

Answer 5

Sentinel pile

Question 6

What is the main RF for an Anal fissure?

Answer 6

Constipation
inflammatory bowel disease
STI’s e.g. HIV, syphilis, herpes

Question 7

What is an anal fistula?

Answer 7

An abnormal cavity that forms between the anal canal to the skin near the anus
Usually get infected and result in an abscess

Question 8

Which condition is an anal fistula common in?

Answer 8

Crohn’s disease

Question 9

How does an anal fistula present?

Answer 9

Pass blood or pus when poo
Smelly discharge around anus
Constant throbbing- worse when sit

Discharge and discomfort

Question 10

What would you see in the poo of someone with an anal fistula?

Answer 10

Pus or blood

Question 11

What is the main investigation of an anal fistula?

Answer 11

DRE
Complex fistula-MRI

Question 12

What is the management of an anal fistula?

Answer 12

Surgical

Question 13

What is the surgical management of an anal fistula?

Answer 13

Fistulotomy

Seton procedure

Question 14

How does an anal abscess present?

Answer 14

Perianal pain and swelling

Fluctuant tender peri anal swelling

Question 15

Is there PR bleeding with an anal abscess?

Answer 15

No

If blood, suspect fissure

Question 16

What other symptoms does an anal abscess present with?

Answer 16

Low grade fever and tachycardia

Question 17

What is an anal abscess associated with?

Answer 17

Crohn’s
Ulcerative colitis
TB

Question 18

What is the management of an anal abscess?

Answer 18

Surgical excision and drainage

Done under local anaesthetic

Question 19

What is classed as an acute anal fissure?

Answer 19

Less than 6 weeks

Question 20

What is classed as a chronic anal fissure?

Answer 20

Lasts longer than 6 weeks

Question 21

What is the management of an acute anal fissure?

Answer 21

soften stool
–dietary advice: high-fibre diet with high fluid intake
–bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried

Question 22

What is the management of a chronic anal fissure?

Answer 22

Topical glyceryl trinitrate (GTN)

Question 23

What can you give for a chronic anal fissure if GTN isn’t effective after 8 weeks?

Answer 23

Refer to secondary care for
–Surgery (sphincterotomy)
or
–Botulinum toxin

Question 24

How is an anal fissure diagnosed?

Answer 24

On history alone
(too painful to do exam)

Question 25

Where do majority of anal fissure occur?

Answer 25

On the posterior midline

Question 26

If there is an anal fissure on somewhere other than the posterior midline what should be considered?

Answer 26

An underlying cause e.g. Crohn's

Question 27

What investigation can be used for a complex anal fistula?

Answer 27

MRI (to evaluate complex fistulae)

Question 28

What can be used to determine the location of an anal fistula?

Answer 28

Goodsall's rule

Question 29

What is there usually a history of in someone presenting with an anal fistual?

Answer 29

History of anorectal abscess

Question 30

What are the possible complications of an anal fistula?

Answer 30

- recurrence - faecal incontinence post-operatively

Question 31

What are the main features of an anorectal abscess?

Answer 31

- anal or rectal pain, often worse on defection - pus-like discharge from anus - fever, rigors - erythematous, indurated or fluctuant mass around anus