Anorectal disorders

Question 1

What is pruritis ani?

Answer 1

Itch that occurs around the anus

Question 2

What can cause pruritis ani?

Answer 2

• Moist/solied anus
• Fissures
• Incontinence
• Poor hygeine
• Tight pants
• Threadworm
• Fistula
• Dermatoses
• Lichen sclerosis
• Anxiety
• Contact dermatitis

Question 3

How would you treat someone with pruritis ani?

Answer 3

• Avoid scratching
• Improve perianal hygeine
• Avoid foods which loosen stool
• Soothing ointment
• Topical steroids (max 2 weeks)
• Oral antihistamine

Question 4

What are anal fissures?

Answer 4

Painful tears in the squamous lining of the lower anal canal. Often, if chronic, they will have a sentinal pile or mucosal tag at the external aspect

Question 5

What sex do anal fissures occur more commonly in?

Answer 5

Males

Question 6

What are causes of anal fissures?

Answer 6

• Hard stools - most common
• Syphillis
• Herpes
• Trauma
• Crohn’s
• Anal cancer
• Psoriasis

Question 7

Why do anal fissures take a significant amount of time to heal?

Answer 7

Spasm around the area leads to relative ischaemia, meaning that fissures take longer to heal

Question 8

What might you consider doing in someone with anal fissures if you suspected a sinister cause?

Answer 8

Proctoscopy/Sigmoidoscopy

Question 9

How would you manage someone with anal fissures?

Answer 9

• Dietary fibre
• Fluids
• Stool softener
• Hygeine advice
• Consider medical
  
  • Topical 5% lidocaine + 0.2% GTN Paste
  • Topical 2% Diltiazem

Question 10

What medical treatment can be used to treat anal fissures?

Answer 10

• Topical 5% lidocaine + 0.2% GTN Paste
• Topical 2% Diltiazem

Question 11

What would you consider dioing in a patient with anal fissures where conservative and medical management has failed?

Answer 11

Lateral partial internal sphinterectomy

Question 12

What is a anorectal abscess?

Answer 12

Abscess which is usually caused by gut bacteria, which can occur in the perianal, ischiorectal, intersphincteric or supralevator regions

Question 13

How would you manage a perianal abscess?

Answer 13

Incise and drain under GA

Question 14

What diseases are perianal abscesses associated with?

Answer 14

• Diabetes mellitus
• CRohn’s
• Malignancy
• Fistulae

Question 15

What is a fistula in ano?

Answer 15

A track communicating between the skin and anal canal/rectum. Often occurs following the development of an abscess

Question 16

How do fistulae in ano form?

Answer 16

Blockage of deep intramuscular gland ducts thought to predispose to the formation of abscesses, which discharge to form fistulas

Question 17

What are causes of fistula-in-ano?

Answer 17

• Perianal sepsis
• Abscesses
• Crohn’s Disease
• TB
• Diverticular disease
• Rectal carcinoma
• Immunocompromise

Question 18

What is the following type of fistula-in-ano?

Answer 18

Transphincteric fistula

Question 19

What is the following type of fistula-in-ano?

Answer 19

Intersphincteric fistula

Question 20

What type of fistula-in-ano is the following?

Answer 20

Extrasphincteric fistula

Question 21

What type of fistula-in-ano is the following?

Answer 21

Suprasphincteric fistula

Question 22

How would you investigate a fistula in ano?

Answer 22

• MRI
• Endoanal US scan

Question 23

How would you manage someone with fistula-in-ano?

Answer 23

• Fistulotomy + excision
  
  • High (transphincteric)- seton suturing tightened over time to maintain continence
  • Low (superficial) - heal by secondary intention

Question 24

What are causes of anal ulceration?

Answer 24

• Crohn’s
• Anal cancer
• Lymphogranuloma venerum
• TB
• Syphillis

Question 25

What is a pilonidal sinus?

Answer 25

Obstruction of the natal cleft hair follicles approximately 6 cm above the anus. In growing hair excites a foreign body reaction and may cause secondary tracks to open laterally, with abscesses extruding foul, smelly discharge

Question 26

What sex does pilonidal sinuses occur most commonly in?

Answer 26

Males

Question 27

What percentage fo those with rectal prolapse are incontinent?

Answer 27

75%

Question 28

Why does rectal prolapse occur?

Answer 28

Lax sphincter, combined with prolonged straining. It is also related to chronic neurological and psycholoigical disorders

Question 29

How would you manage someone with rectal prolapse?

Answer 29

* **Abdominal approach** - fix rectum to sacrum (rectoplexy) +/- mesh insertion +/- rectosigmoidectomy * **Perineal approach** - Delorme's procedure - resect close to dentate line and suture mucosal bouncaries

Question 30

What are risk factors for the development of anal cancer?

Answer 30

* **Anoreceptive intercourse** * **HPV** * **HIV**

Question 31

Where do anal tumours above the dentate line spread to?

Answer 31

Pelvic lymph nodes

Question 32

Where do anal cancers spread to if they are below the dentate line?

Answer 32

Inguinal lymph nodes

Question 33

How do those with anal cancer tend to present?

Answer 33

* **Bleeding** * **Pain** * **Bowel habit change** * **Pruritis ani** * **Masses** * **Stricture**

Question 34

How would you manage someone with anal cancer?

Answer 34

* **Chemoradiotherapy** - radio + flourouracil + mitomycin/cisplatin * **Consider surgery**

Question 35

What are haemorrhoids?

Answer 35

Disrupted and dilated anal cushions. The anus is lined mainly by discontinuous masses of spongy vascular tissue - anal cushions - which contribute to anal closure. These are prone to disruption and displacement, and can protrude forming piles Trauma to these piles can lead to leaking of the capillaries of underlying lamina propria PILES ARE NOT VARICOSE VEINS

Question 36

Why are haemorrhoids above the dentate line not normally painful

Answer 36

No sensory fibres above the dentate line - not painful unless they thrombose and are gripped by anal sphincter

Question 37

What are causes of haemorrhoids?

Answer 37

* **Constipation with prolonged staining** - main cause * **Congestion** - pelvic tumour * **Pregnancy** * **CCF** * **Portal hypertension**

Question 38

What is the pathogenesis of haemorrhoids?

Answer 38

VAscular cushion protrudes through the tight anus, becomes more congested, and hypertrophy to protrude again more readily. These protrusions may then strangulate

Question 39

What are symptoms of haemorrhoids?

Answer 39

* **Bright red rectal bleeding** - often coating stools/on tissue/dripping into toilet * **Mucous** * **Pruritis ani** * **Pain** * **Severe anaemia can occur**

Question 40

What features might suggest a more sinister cause of what you initially think are haemorrhoids?

Answer 40

* **WEight loss** * **Tenesmus** * **Change in bowel habit**

Question 41

Whaat are important aspects of the examination that you need to consider when examining someone with suspected haemorroids?

Answer 41

* **Abdo exam** - look for sinister pathology * **PR exam** - prolapsing piles, other pathology * **Colonoscopy/flexible sigmoidoscopy if proximal pathology suspected**

Question 42

What is classed as a first degree haemorrhoid?

Answer 42

Remains in the rectum

Question 43

What is classed as a 2nd degree haemorrhoid?

Answer 43

Prolapse through the anus on defecation but spontaneously reduce

Question 44

What is classed as a 3rd degree haemorrhoid?

Answer 44

Prolapse on defecation but require digital reduction

Question 45

What is classed as a 4th degree haemorrhoid?

Answer 45

Remain persistently prolapsed

Question 46

Where do internal haemorrhoids originate from?

Answer 46

Above the dentate line

Question 47

Where do external haemorrhoids originate from?

Answer 47

Below dentate line

Question 48

Where do mixed haemorrhoids originate from?

Answer 48

Both above and below dentate line

Question 49

How would you manage haemorrhoids?

Answer 49

**Conservative/Medical** - 1st degree * **High fibre diet + fluids** * **Topical analgesia** * **Stool softeners** **Interventional** - 2nd and 3rd degree * **Sclerotherapy** * **Band ligation** * **Infrared coagulation** * **Bipolar diathermy** **Surgical** * **Excisional Haemorrhoidectomy** * **Stapled haemorrhoidopexy**