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General (Surgery) > Anorectal > Flashcards

Anorectal Flashcards

1
Q

what are haemorrhoids

A

defined as abnormal swelling or enlargement of the anal vascular cushions

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2
Q

what is the normal function of the anal vascular cushions

A

assist the anal sphincter in maintaining continence

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3
Q

describe the classification of haemorrhoids

A

type 1 = remain in the rectum

type 2 = prolapse through the anus on defecation but spontaneously reduce

type 3 = prolapse through the anus on defecation but require digital reduction

type 4 = remain persistently prolapsed

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4
Q

risk factors for haemorrhoids

A

excessive straining (from chronic constipation)

increasing age

raised intra-abdominal pressure (pregnancy, chronic cough)

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5
Q

clinical features of haemorrhoids

A

painless bright red rectal bleeding - commonly after defecation and often seen on the paper

pruritus and rectal fullness/anal lump

large prolapsed haemorrhoids can thrombose - these present as very painful and usually to the A&E department

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6
Q

investigations into haemorrhoids

A

proctoscopy is usually performed to confirm the diagnosis

colonoscopy is also advised to rule out any concurrent anorectal pathology

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7
Q

management of haemorrhoids

A

most managed conservatively; lifestyle advice (increase fibre intake, laxatives, increased fluid intake, avoid oral opioid analgesia) - all aim to avoid constipation

rubber band ligation can be used on type 1 and 2 haemorrhoids

haemorrhoidal artery ligation used on type 2 and 3 - same result as above - it infarcts and falls off

haemorrhoidectomy is another surgical option but carries a risk of faecal incontinence if any internal sphincter muscle is excised

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8
Q

if a haemorrhoid appears swollen and purple, what is the most likely diagnosis

A

thrombosed haemorrhoid

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9
Q

what is pilonidal sinus disease

A

formation of a sinus in the cleft of the buttocks - commonly affects men aged 16-30

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10
Q

pathophysiology of pilonidal sinus disease

A

starts from a hair follicle in the intergluteal cleft (bumcrack) becoming inflamed or infected

inflammation obstructs the opening of the follicle, which extends inwards, forming a pit (characteristic feature)

a foreign body type reaction may then lead to formation of a cavity, connected to the surface of the skin by an epithelialised sinus tract

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11
Q

risk factors for pilonidal sinus disease

A

caucasian males with coarse dark body hair

sitting for long periods of time e.g. lorry driver

increased sweating, buttock friction, obesity, poor hygeine

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12
Q

pilonidal sinus vs perianal fistula

A

pilonidal sinus doesn’t communicate with the anal canal like perianal fistulas do

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13
Q

clinical features of pilonidal sinus disease

A

discharging and intermittently painful sinus

if it becomes infected it can cause a pilonidal abscess - swollen and erythematous with systemic features of infection

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14
Q

management of pilonidal sinus disease

A

conservative; shaving affected region and plucking the sinus free of any hair that is embedded, wash sinus out to prevent infection

surgical; any abscess requires surgical drainage

(chronic disease is treated by the removal of the actual pilonidal sinus tract)

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15
Q

what is a perianal fistula

A

abnormal connection between the anal canal and the perianal skin

typically occurs as a consequence of an anorectal abscess

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16
Q

risk factors of perianal fistulas

A

associated with anorectal abscess

diabetes

inflammatory bowel disease - mainly crohn’s disease

trauma to anal region

previous radiation therapy to the anal region

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17
Q

clinical features of anorectal fistula

A

presents with either; recurrent anorectal abscesses, or discharge onto the perineum (mucus, blood, pus or faeces)

on examination, an external opening of the perineum may be seen

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18
Q

investigations into anorectal fistulas

A

MRI pelvis to view the anatomy of the tract

19
Q

what management strategies are in place for an anorectal fistula

A

fistulotomy - cutting the tract open and allowing it to heal by secondary intention

placement of a seton drain - drains the fistula to prevent infection

20
Q

what is most commonly associated with anorectal fistula formation

A

anorectal abscess

21
Q

what is the pathophysiology of anorectal abscesses

A

thought to be caused by plugging of the anal ducts, which drain the anal glands in the anal wall (helping to ease the passage of faecal matter using mucous secretions)

blockage results in fluid stasis and consequently infection - most commonly by E. coli

22
Q

what is the most common organism involved in anorectal abscesses

A

E. coli

23
Q

where is the most common site of anorectal abscess

A

peri anal

24
Q

clinical features of anorectal abscesses

A

severe pain in perianal region - worse on sitting down

discharge and bleeding - severe abscesses can also show systemic signs; fever, rigor, general malaise

on examination; an erythematous, fluctuant and tender perianal mass will be palpable

25
Q

investigations into anorectal abscesses

A

clinical diagnosis - but most require surgery so; routine bloods, group and save. clotting

check for underlying risk factors - HbA1c for diabetes, check for crohn’s via MRI pelvis

26
Q

management of anorectal abscess

A

start on abx and analgesia

surgical; incision and drainage under general anaesthetic

also an intra-operative proctoscopy to check for presence of any fistula - if found a seton drain can be inserted

27
Q

what is an anal fissure and how are they caused

A

a tear in the mucosal lining of the anal canal usually caused by trauma from defecation of hard stool

28
Q

risk factors for anal fissures

A

constipation

dehydration

inflammatory bowel disease

chronic diarrhoea

29
Q

clinical features of anal fissures

A

intense pain post defecation

bleeding (bright red on wiping) and itching post defecation

30
Q

management of anal fissures

A

conservative; increase fibre and fluid intake, laxatives to soften stool, GTN cream to relax the anal sphincter, analgesia

surgical; used in chronic cases - botox injections into the internal and external anal sphincter to relax it and promote healing, or a lateral sphincterotomy

31
Q

what are the 2 main types of rectal prolapse

A

partial thickness - rectal mucosa protrudes out of the anus

full thickness - rectal wall protrudes out of the anus

32
Q

what condition does rectal prolapse most commonly co-exist with

A

haemorrhoids

33
Q

risk factors for rectal prolapse

A

increasing age

female gender

multiple deliveries

straining

34
Q

clinical features of rectal prolapse

A

rectal mucus discharge, PR bleeding, faecal incontinence, visible ulceration

rectal fullness, tenesmus or repeated defecation - because full thickness prolapses often start internally

35
Q

management of rectal prolapse

A

conservative; increase fibre and fluid intake

surgical; (only definitive management) - abdominal approach and perineal approach

36
Q

what type are the majority of anal cancers and where are the most commonly found

A

squamous cell carcinomas found below the dentate line

37
Q

what is anal intra-epithelial neoplasia

A

precancerous condition that can affect either the perianal skin or anal canal - linked to the development of squamous cell carcinomas

strongly linked to the infection with the HPV

38
Q

which virus is anal intraepithelial neoplasia strongly linked with

A

Human Papilloma virus (HPV)

39
Q

risk factors for developing anal cancer

A

HPV - accounts for 80-90%, especially HPV-16 and HPV-18

HIV infection

increasing age

smoking

immunosuppression

crohn’s disease

40
Q

main symptoms of anal cancer

A

rectal pain and rectal bleeding

anal discharge, pruritus or presence of palpable anal mass

faecal incontinence and tenesmus can potentially be involved

41
Q

where does lymph drain to from above vs below the dentate line

A

below = superficial inguinal nodes

above = para-aortic and paravertebral nodes

42
Q

what lymph nodes should you check in anal cancer below the dentate line

A

superficial inguinal nodes

43
Q

investigations into anal cancer

A

proctoscopy to visualise anal canal

examination under anaesthetic - also allows for biopsy to be taken and better ability to see size and local invasion

HIV test in those with risk factors

MRI pelvis, CT-chest-abdo-pelvis = assess for local invasion and distant mets

44
Q

management of anal cancer

A

first choice = chemo-radiotherapy

surgical; reserved for advanced disease after failure of chemo-radiotherapy

General (Surgery) (7 decks)

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