Anorectal Disease Flashcards
(69 cards)
1
Q
What’s anal fissure?
Definition of acute and chronic anal fissure
A
Anal fissures are tears of the squamous lining of the distal anal canal.
- if present for less than 6 weeks → ACUTE
- if present for more than 6 weeks → CHRONIC
2
Q
(3) risk factors for anal fissures
A
- constipation
- inflammatory bowel disease
- sexually transmitted infections e.g. HIV, syphilis, herpes
3
Q
Causes of anal fissure
A
- trauma secondary to the passage of hard stool
- associated with constipation
- spasm of internal anal sphincter contributes to pain and → ischaemia + poor healing
- Commoner in women
• Rarer causes:
- Crohn’s
- Herpes
- Anal Ca
4
Q
Presentation of anal fissure
A
- Intense anal pain
- Especially on defecation
- May prevent pt. from passing stools
- Fresh rectal bleeding
- On paper mostly
5
Q
Examination of anal fissure
A
PR often impossible due to pain
Inspection
• Midline ulcer is seen
- Usually posterior @ 6 O’clock
- May be anterior
• May be a mucosal tag – sentinel pile
-usually posterior @ 6 O’clock
• Groin LNs suggest complicating factor: e.g. HIV
6
Q
Management of acute anal fissure
A
Management of an acute anal fissure (< 6 weeks)
- dietary advice: high-fibre diet with high fluid intake
- bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
- lubricants such as petroleum jelly may be tried before defecation
- topical anaesthetics e.g. lignocaine
- analgesia
7
Q
Management of chronic anal fissure
A
Management of a chronic anal fissure (> 6 weeks)
- the above techniques should be continued
- topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
- if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery or botulinum toxin
8
Q
What’s fistula in ano?
A
Abnormal connection between ano-rectal canal and
the skin
9
Q
Pathophysiology of anal fistula
A
- Blockage of intramuscular glands → abscess → abscess discharges to form a fistula
10
Q
Conditions associated with anal fistula
A
- Crohn’s
- Diverticular disease
- Rectal Ca
- Immunosuppression
11
Q
Classification of fistula in ano (2)
A
- High: cross sphincter muscles above dentate line
- Low: cross sphincter muscles below dentate line
12
Q
What’s Goodshall’s role?
A
Goodsall’s Rule → determines path of fistula tract
- Fistula anterior to anus track in a straight line (radial)
- Fistula posterior to anus always have internal opening at the 6 o’clock position → curved track
13
Q
Presentation of fistula in ano (2)
A
- Persistent anal discharge
- Perianal pain or discomfort
14
Q
Findings on examination of fistula in ano
A
- May visualise external opening: may be pus
- Induration around the fistula on DRE
- Proctosopy may reveal internal opening
15
Q
Ix for fistula in ano (2)
A
- MRI
- Endoanal US
16
Q
Management of:
- low fistula
- high fistula
A
Extent of fistula must first be delineated (visualised) by probing the fistula during examination under anaesthetic
Low Fistula
- Fistulotomy and excision
- Laid open to heal
High Fistula
• Fistulotomy could damage the anorectal ring
• Suture – a seton – passed through fistula and
gradually tightened over months
-Stimulates fibrosis of tract
-Scar tissue holds sphincter together
17
Q
A
18
Q
Upper 2/3 of the anal canal
- what epithelium
- sensation
- what artery and vein
- what lymph nodes
A
Upper 2/3 of canal
- Lined by columnar epithelium
- Insensate
- Superior rectal artery and vein
- Internal iliac nodes
19
Q
Lower 1/3 of the anal canal
- epithelium
- sensation
- artery and veins
- lymph nodes
A
Lower 1/3 of canal
- Lined by squamous epithelium
- Sensate
- Middle and inf. rectal arteries and veins
- Superficial inguinal nodes
20
Q
What are:
- dentate line
- white line
A
- Dentate line = squamomucosal junction
- White line = where anal canal becomes true skin
21
Q
What are (3) anal sphincters?
A
- Internal anal sphincter
- External anal sphincter
- Anorectal ring
22
Q
Anal sphincters:
A. Internal:
- role and control
B. External: structure and control
A
Internal
- Thickening of rectal smooth muscle
- Involuntary control
External
- Three rings of skeletal muscle (Deep, superficial, subcutaneous)
- Voluntary control
23
Q
What’s perianal haematoma?
A
- Subcutaneous bleeding from a burst venule → caused by straining or the passage of hard stool
- Also called an external pile
24
Q
Presentation of Perianal haematoma
A
- Tender blue lump at the anal margin
- Pain worsened by defecation or movement
25
Management of **perianal haematoma** (2)
* Analgesia + spontaneous resolution
* Evacuation under LA
26
**Proctalgia fugax**
## Footnote
- common group of patients
- what is this
- associated with which condition
**Group:** Young, anxious men
**Proctalgia fugax**: Crampy anorectal pain, worse @ night
• Unrelated to defecation
**Association**: trigeminal neuralgia
27
Management of **proctalgia fugax**
* Reassurance
* GTN cream
28
**Perianal warts**
- common group of patients
Perianal warts
homosexual men (men who have sex with men)
29
Types (2) of **perianal warts** and what's the difference + treatment?
Perianal warts
## Footnote
A. **Condylomata accuminata
•** HPV
• Rx: podophyllin paint, cryo, surgical excision
B. **Condylomata lata**
•Syphilis
• Rx: penicillin
30
What are haemorrhoids?
* Haemorrhoidal tissue → part of the normal anatomy; contributes to anal continence
* They are mucosal vascular cushions
* found in the left lateral, right posterior and right anterior portions of the anal canal (3 o'clock, 7'o'clock and 11 o'clock respectively)
* Haemorrhoids are said to exist when they become enlarged, congested and symptomatic
31
Clinical features of haemorrhoids
* painless rectal bleeding is the most common symptom
* pruritus
* pain: usually not significant unless piles are thrombosed
* soiling may occur with third or forth degree piles
32
Pathophysiology of haemorrhoids
* Gravity, straining → engorgement and enlargement of anal cushions
* Hard stool disrupts connective tissue around
cushions
* Cushions protrude and can be damaged by hard stool → bright red (capillary) bleeding.
33
Two types of haemorrhoids and what's the difference
**External**
* originate below the dentate line
* prone to thrombosis, may be painful
**Internal**
* originate above the dentate line
* do not generally cause pain
34
Classification of haemorrhoids
35
What contributes to the development of haemorrhoids (causes)
Constipation with prolonged straining
• Venous congestion may contribute
- Pregnancy
- Abdominal tumour
- Portal HTN
36
Examination of haemorrhoids
* full abdo exam → palpating for masses
* Inspect perianal area: masses, recent bleeding
* DRE: can’t palpate piles unless thrombosed
* Rigid sigmoidoscopy → to identify higher rectal
37
Conservative and medical management of haemorrhoids
**Conservative**
* ↑ fibre and fluid intake
* Stop straining @ stool
**Medical**
* Topical preparations
* Anusol: hydrocortisone
* Topical analgesics
* Laxatives: lactulose, fybogel
38
Interventional management for haemorrhoids (4) and its SEs
**Interventional**
A. **Injection** with **sclerosant** (5% phenol in Almond oil)
- Injection above dentate line
- SE: impotence, prostatitis
B. **Banding** → thrombosis and separation
-SE: bleeding, infection
C. **Cryotherapy**
-SE: watery discharge post-procedure
D. **Infra-red coagulation**
39
Surgical intervention for haemorrhoids (1)
- name
- discharge prescription
- SEs
**Haemorrhoidectomy**
## Footnote
* Excision of piles + ligation of vascular pedicles
* Discharge with laxatives post-op
* SE: bleeding, stenosis
40
Management of **Acutely thrombosed external haemorrhoids**
Acutely thrombosed external haemorrhoids
* if patient presents within 72 hours then referral should be considered for excision
* Otherwise patients can usually be managed with stool softeners, ice packs and analgesia (topical lignocaine jelly)
* Symptoms usually settle within 10 days
41
Presentation of acutely thrombosed external haemorrhoids
* typically present with significant pain
* examination reveals a purplish, oedematous, tender subcutaneous perianal mass
42
Pathogenesis of **Perianal sepsis/abscess**
* Anal gland blockage → infection ( e.g. E.coli) → abscess
* May develop from skin infections
- E.g. sebaceous gland or hair follicle
- Staphs
43
(3) conditions associated with the development of anal abscesses
* Crohn’s
* DM
* Malignancy
44
Classification and symptoms of **anal abscess (4)**
* Perianal: 45%
- discrete local red swelling close to the anal verge
* Ischiorectal: ≤30%
- systemic upset
- Extremely painful on DRE
* Interphincteric / intermuscular: \>20%
* Pelvirectal / supralevator: ~5%
- Systemic upset
- Bladder irritation
45
Presentation of anal abscess
* Throbbing **perianal pain** → worse on sitting
* Occasionally a purulent anal discharge
46
Examination of anal abscess
* Perianal mass or cellulitic area
* Fluctuant mass on PR
* Septic signs: fever, tachycardia
47
Management of anal abscess
* antibiotics
Most cases require **examination under anaesthesia with incision and drainage**
- Wound packed
- Heals by secondary intention
- Daily dressing for 7-10 days
\* Look for an anal fistula which complicates ~30% of
abscesses
48
What's **Pilonidal Sinus**?
* Pilonidal: latin → “nest of hair”
* Sinus: blind ending tract, lined by epithelial or
granulation tissue, which opens onto an epithelial
surface
49
Pathophysiology of **Pilonidal sinus**
* Hair works its way beneath skin → foreign body reaction → formation of abscess
* Usually occur in the natal cleft
50
Risk factors for **Pilonidal abscess**
* M\>F=4:1
* Geo: Mediterranean, Middle east, Asians
* Often overweight with poor personal hygiene
* Occupations with lots of sitting: e.g. truck drivers
51
Presentation of **pilonidal abscess**
* Persistent discharge of purulent or clear fluid
* Recurrent pain
* Abscesses
52
Management of **pilonidal abscess**
**Conservative**
* Hygiene advice
* Shave / remove hair from affected area
**Surgical**
* Incision and drainage of abscesses
* Elective sinus excision
- Methylene blue to outline tract
- Recurrence in 4-15%
53
Types of anal cancers
* **80% SCCs**
**Other:**
- melanomas
- adenocarcinomas
54
Anal margin tumours
- type
- prognosis
Anal margin tumours
- Well differentiated keratinising lesions
- Commoner in men
- Good prognosis
55
Anal canal tumours
- origin
- type
- prognosis
**Anal canal** tumours
- Arise above dentate line
- Poorly differentiated, non-keratinising
- Commoner in women
- Worse prognosis
56
Spread of anal carcinoma (2)
* Above dentate line → internal iliac nodes
* Below dentate line → inguinal nodes
57
Conditions associated with **anal carcinoma**
* HPV (16, 18, 31, 33) is important factor
- ↑ incidence in men who have sex with men
- ↑ incidence if perianal warts
58
Possible presentations of anal cancer
* Perianal pain and bleeding
* Pruritis ani
* Faecal incontinence
- 70% have sphincter involvement @
presentation
* possible → rectovaginal fistula
59
Clinical examination of anal cancer
* Palpable lesion in only 25%
* ± palpable inguinal nodes
60
Investigations of anal cancer
↓• Hb (ACD)
* Endoanal US
* Rectal EUA + biopsy
* CT / MRI: assess pelvic spread
61
Management of anal cancer
* Chemoradiotherapy: most ptatients
* Surgery in:
- Tumours that fail to respond to radiotherapy
- GI obstruction
- Small anal margin tumours w/o sphincter
involvement
62
What's **rectal prolapse?**
Protrusion of rectal tissue through the anal canal
63
Classification of rectal prolapse (2)
**Type 1: Mucosal prolapse**
* Partial prolapse of redundant mucosa
* Common in children: esp with CF
* Essentially large piles \ same Rx
**Type 2: Full thickness prolapse**
* Commoner CF type 1
* Usually elderly females with poor O&G Hx
64
Presentation of rectal prolapse
* Mass extrudes from rectum on defecation
- may reduce spontaneously or require manual
reduction
-May become oedematous and ulcerated→ pain and bleeding
* Faecal soiling
* Associated with vaginal prolapse and urinary incontinence
65
Clinical examination of **rectal prolapse**
* visible prolapse: brought out on straining
* ± excoriation and ulceration
* ↓ sphincter tone on PR
* Assoc. uterovaginal prolapse
66
Investigations in **rectal prolapse**
Si•gmoidoscopy to exclude proximal lesions
* Anal manometry
* Endoanal US
* MRI
67
Management of **partial rectal prolapse**
**Partial Prolapse**
## Footnote
* Phenol injection
* Rubber band ligation
* Surgery: *Delorme’s Procedure*
68
Conservative management of **complete rectal prolapse**
- Pelvic floor exercises
- Stool softeners
69
Surgery for **complete rectal prolapse (2)**
**Surgery**
* Abdominal Approach: ***Rectopexy***
- Lap or open
- Mobilised rectum fixed to sacrum with mesh
* Perineal Approach***: Delorme’s Procedure***
- Resect mucosa and suture the two
mucosal boundaries
