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Flashcards in Anorectal disease Deck (56):
1

Causes of perianal pain

1. Anal fissure

2. Hemorrhoids

3. Colitis

4. Perineal abscess

5. Anorectal carcinoma

2

Classification of hemorrhoids

Class 1: Seen on examination

Class 2: Prolapse but reduce spontaneously

Class 3: Manual reduction required

Class 4: Not reducible

3

Conservative Management anal fissure

1. High-fibre diet

2. Adequate fluid intake

3. Sitz baths

4. Topical analgesia

5. Glycerin trinitrate intra-anal

6. Stool softeners/osmotic/stimulant: docusate sodium, polyethylene glycol, bisacodyl

4

Management of hemorrhoids

High fibre diet, stool softeners Fluids Sitz bath Avoidance of straining Band ligation, infrared coagulation Hemorrhoidectomy

5

Important differential with non-healing anal fissue or fissure located other than posterior area of anus

Crohn Malignancy

6

Etiology and definition of anal fissure

1. Longitudinal ulcer in skin lined anal canal

2. Etiology- most commonly associated with passage/trauma when passing hard stool

7

Symptoms of anal fissure

1. pain during and after defecation Internal spincter spasm= ++pain

2. PR bleeding

3. Pruritis

4. Constipation

5. Discharge

8

Diagnosis of anal fissure

History

Clinical examination

-->most common posteriorly, if anterior consider underlying condition

Tear

Sentinel skin tag

9

Surgical management of anal fissure

1. Internal lateral sphincterotomy->incision of internal sphincter, not past dendate line

2. Fluids, fibre, bulking agents

3. After procedure may have key hole defect->incision may not heal properly leading to passive soiling

10

Mechanism of chronic anal fissure

Fissure->pain->+sphincter tone->ischemia->fissure

Will see anal papilla, exposed fibres of sphincter and anal skin tag

11

Classification of anorectal abscess

Perianal most common, fistula in ano posterior

Ischiorectal, transphincteric

Intersphincteric

Supralevator, suprasphicteric

Extrasphincteric

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12

Etiology of abscess

Blocked anal gland->infected

13

Risks for perianal abscess

DM Immunocompromised Chrohs

14

Clinical features of perianal abscess

Throbbing, swollen, erythematous, discharge, fever

15

Management of perianal abscess

1. Analgesia

2. Start fluids->keep NBM, surgical consult

3. Surgical drain

4. Have warm baths/clean 2-3 day

5. Consider antibiotics if polymicrobial, immunocompromised, DM, elderly ->Gentamicin, ampicillin + metronidazole

6. Fluids, fibre, avoid hard stools

16

Risk factors for anorectal abscess and differential

1. Fistula

2. Chron's

3. Male

Differential

1. Chrohns

2. Infected sebaceous gland

3. Hydradenitis suppurativa

17

Etiology of fistula in ano

Idiopathic Infection Crohns TB Cancer Iatrogenic Trauma Foreign body Radiation

18

Symptoms in fistula

Recurrent abscess Discharge Pain/discomfort

19

Diagnosis and investigations in fistula

1. Examination->may find end tract on PR.

2. Should determine level of internal opening in relation to levator mechanism

-->Anterior ex open- drain into anus at dendate line

-->Posterior take curved to enter anal canal in midline

3. Investigations:

Sigmoidoscopy to rule out inflammatory bowel examine under anaesthesia

Fistulogram

Endoluminal US

MRI useful in complex

20

Management of high and low fistula

1. Low(does not cross many spinchter muscles)->lay tract open with fistulotomy: can heal via secondary intention

2. High (does cross sphincter muscles)->requires

a. seton procedure, or else with have flow incontinence, allows drainage of fistula + healing

b. Advancement flap->repair of internal gland with suture, then advancing skin to cover fistula

21

Clinical features in anal cancer

Pain

Pruritis

Bleeding

Moisture

Most commonly epidermoid type (SCC and variants)

22

Risk factors for anal cancer

Homosexual males

HPV

Anal sex

Syphillis/LGV HIV

Tobacco

23

Spread and detection of anal cancer

Spreads via lymphatics, usually detected late

24

Staging in anal cancer

Stage I T1 N0 M0

Stage II T2 N0 M0; T3 N0 M0

Stage III Tany N1 M0

Stage IV Tany Nany M1

T1 Tumour ≤ 2 cm in greatest dimension

T2 Tumour > 2–5 cm

T3 Tumour > 5 cm

T4 Tumour invades adjacent organ (vagina, urethra, bladder)

N0 No regional lymph node metastases

N1 Perirectal lymph node metastases

N2 Unilateral internal iliac/inguinal

N3 Perirectal and inguinal/bilateral internal/inguinal

M0 No distant metastases

M1 Distant metastases

25

Etiology of pruritis ani

Idiopathic Poor hygiene Haemorrhoids Fissure-in-ano Drug hypersensitivity and allergies Anal warts Fungal infection Parasites Faecal incontinence Anal cancer Premalignant conditions (e.g. Bowen’s disease) Systemic disease (e.g. renal failure, diabetes mellitus)

26

Management of pruritus ani

Management: Consider any underlying cause Wash with soft pad after defecation Avoid humid, perfumed Cotton underwear Avoid medicated soaps

27

Define internal and external hemorrhoids

Internal when from above dendate line External when below dendate line

28

Anatomy of anal canal

Includes

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29

Define a pilonidal sinus

1. Caused by a forceful insertion of a hair in the natal cleft->intense inflammatory response and epithelialisation.

2. May be multiple and communicate via a deep cavity

3. Chronic discharge is common

4. Infection can occur->abscess

30

What is this

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Pilonidal sinus

31

Epidemiology of pilonidal sinus

1. Male

2. 20 yo

3. Hirsute

32

Pathophysiology of pilonidal sinus

1. broken hair is driven into the skin of the natal cleft by a rolling action of the buttocks. This provokes a foreign body-type reaction, and chronic inflammation results in a mature sinus.

33

Clinical features of pilonidal sinus, diagnosis

1. Sacrococcygeal discharge

2. Sacrococcygeal pain and swelling

3. Sinus tracts

4. History of priior rupture of fluid in natal cleft

5. Skin maceration

May become infected->fever and toxic, uncommon

Clinical diagnosis

 

34

Management: aymptomatic, w/o, w/ abscess and recurrent

1. Hair removal + local hygeine

Symptomatic->

2. Surgical (recurrent, failure of incision and drain, complex)

Excision and drainage under local/general

Karydakis->asymmetric flap

Unroofing w/ marsupialisation

Primary or secondary

3. Antibiotics->amoxycillin/clavulanate

4. Laser depilation hair removal

35

Arterial supply of the rectum and anus

1. Superior rectal artery upper rectum from inferior mesenteric

2. Middle rectal artery from internal iliac

3. Inferior rectal from pudendal (branch of iliac)->supplies lower rectum and anus

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36

Lymphatic drainage of rectum and anus

1. Superior rectum-> inferior mesenteric

2. Inferior rectum->pararectal nodes

3. Anus->inguinal nodes

37

Label

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1. Rectal area->columnar, insensitive to pain

2. Transitional area->flattened cuboidal columnar

3. Anal area->stratified squamous, no hair or sweat, sensitive to pain

4. Normal skin

38

What is the difference between hydradenitis suppuritiva and anal cryptic gland disease in relation to region they occur

1. Hydradenitis suppurative is disease of the skin glands->occurs in region 4

2. Anal cryptic gland disease-> occurs in region 2

39

Label

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5. Anal crypt->giving rise to glands, location of anal fissure

6. Anal glands

7. Dendate line

8. Anal cushion-> hemorrhoids

40

Coronal section MRI anus and rectum identify structures

Identify

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41

Label pelvic floor muscles

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9. Levator plate including levator ani

10. Puborectalis (part of levator ani + PC, IC)

11. External sphincter

42

Label

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12. Internal anal sphincter

13. Rectal wall

43

Key tissue spaces label

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14. Intersphincteric->infection of anal crypt gland can cause infection here

15. Supralevator->abscess can occur here

16. Ischiorectal->less pain because tissue is fat and can expand. Fistula here ++incntinence ->repair involves cutting muscle, not function properly as sphincter

44

Differential for anal fissure

1. Ulcer

Crohns

Syphillis

TB

2. Pain

Thrombosed external pile

Intersphincteric abscess

Herpes

Cancer

45

Pathogenesis of hemorrhoids

1. AV channels in the anal cushions

2. Channels increase and decrease in size

3. EAS important in continence

4. IAS prevents liquid leakage. It is a fatigue resistant muscle

5. Anal cushions prevent leakage of small amounts of liquid and gas

6. Straining= engorgement of anal cushions= fragmentation of muscular mucosa= bleeding and prolapse

7. Lack of fibre= engorgement of anal cushions

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46

Function of anal cushions

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47

Management of hemorrhoids: Non prolapsing / reducible

1. Reduce, topical corticosteroids for grade 1

2. Fibre, hydration, manage constipation

3. Rubber band ligation (can do three at once w/o risk of stricture)

4. Photocoagulation, arterial ligation sclerothermy

48

Management of hemorrhoids: Irreducible

1. Diet, lifestyle...

2. Band ligation (Grade 3)

3. Hemorrhoidectomy (Grade 4 internal or external)

49

Details of hemorrhoidectomy and complications

1. Procedure

  • Type 1
    • details
      • Use diathermy – cut below the anal cushion but above internal sphincter (must find correct plane!!!)
      • Dissect to the rectum
      • No ligatures – heal by secondary intention
    • Complications
      • Anal stricture, bleeding, incontinence
    • Post op
      • Keep clean
  • Type 2
    • Stapling – has better results, +recurrence

2. Following

Recovery 2 weeks

High fiber, fluids, stool softners, sitz bath, analgesia

R/V with GP if ++pain, bleeding, fever

50

What is a perianal hematoma and management

1. Thrombosis of SC perianal plexus

2. Three day rule

If w/i 3 days of pain onset, incise to relieve pressure

Following 3 days, pain will resolve, leave alone

51

Fibrous anal polyp important points

1. Not a rectal polyp

2. Colour of skin, not pink like mucosa or purple like transitional zone

3. Pain sensitive, not for rubber band ligation

52

Features of anal crohns

1. Multiple anal lesions

2. Edematous skin tags

3. Blue crimson coloration of skin

4. Involvement of labia or groin

5. Indolent (non painful) ulceration

6. Extensive anorectal sepsis

7. High fistula->including rectovaginal fistula

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53

Management of anal crohns

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54

What is hydradenitis suppurativa- presentation, treatment

1. Infection of apocrine skin glands, due to increased viscosity

2. Young post puberty, associated with acne

3. Tender discharging

4. Induration->fibrosis

5. Associated with fistula in ano and SCC

6. Laying open or local excision, prophylactic antibiotics considered

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55

Perianal STD: infection, clinical, rectum, special

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56

Perianal melanoma and SCC, Pagets of anus

1. Melanoma

Rare, blue anal nodule. May confuse with thrombosed hemorrhoid. 

Biopsy

12-18 mo mean survival, rapid mets

Palliate excision

2. Anal SCC

Behaves like skin cancer

Can co-exist with hemorrhoids + CRC

3. Pagets

Treatment resistant eczema-> due to underlying adenoCa. Needs biopsy

Exclude rectal Ca

Manage with WLE