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Flashcards in General Surgery - Anorectal Deck (26)
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What are the sx of haemorrhoids?

  • Painless bright red rectal bleeding
  • Pruritus
  • Rectal fullness or an anal lump, and soiling
  • Severe anaemia 


How are haemmorhoids investigated?

  • Abdo exam 
  • PR exam (internal haemmorhoids are not palpable) 
  • Proctoscopy 
  • Sigmoidoscopy 


How are haemmorhoids treated? 

  1. Medical: (1st-degree.) ↑Fluid and fibre is key ± topical analgesics & stool softener (bulk forming). Topical steroids for short periods only.
  2. Non-operative: (2nd & 3rd degree, or 1st degree if medical therapy failed.)
    • Rubber band ligation. Banding produces an ulcer to anchor the mucosa (SE: bleeding, infection; pain)
    • Sclerosants:  (1st- or 2nd-degree.) 2mL of 5% phenol in oil is injected into the pile above the dentate line, inducing fibrotic reaction. .
  3. Surgery:
    • Haemmorhoid artery ligaton
    • Excisional haemorrhoidectomy
    • Stapled haemorrhoidopexy 


What is Pilonidal sinus disease? 

  • Disease of the inter-gluteal region*, characterised by the formation of a sinus in the cleft of the buttocks
  • Commonly affects males aged 16-30 years
  • It is starting from a hair follicle in the intergluteal cleft becoming infected or inflamed


How does pilonidal sinus disease present? 

  • Intermittent red, painful, and swollen mass in the sacrococcygeal region
  • Commonly discharge from the sinus
  • Pilonidal sinus opens up onto the skin, but does not communicate with the anal canal


How do you manage pilonoidal sinuses? 

  • Conservative: shaving the affected region and plucking the sinus free of any hair. Abx
  • Surgical
    • Incision and drainage; chronic: removal of the pilonidal sinus tract.
    • Excising the tract and laying open the wound


What is a perianal fistula? 

 Abnormal connection between the anal canal and the perianal skin


What are some of the causes of peri anal fistula? 

  • IBD – Crohn’s/ UC
  • Systemic diseases – Tuberculosis, diabetes, HIV
  • Trauma hx - to the anal region
  • Previous radiation therapy to the anal region


How would we predict the trajectory of fistula? 

The Goodsall Rule

  • External opening posterior to the transverse anal line – fistula tract will follow a curved course to the posterior midline
  • External opening anterior to the transverse anal line – fistula tract will follow a straight radial course to the dentate line


What classification is used to divide anal fistula into four distinct types: 

Park’s classification system​

  1. Inter-sphincteric fistula (most common)
  2. Trans-sphincteric fistula
  3. Supra-sphincteric fistula (least common)
  4. Extra-sphincteric fistula


How are fistula managed? 


  • A fistulotomy: laying the tract open by cutting through skin and subcutaneous tissue, allowing it to heal by secondary intention
  • The placement of a seton: (suitable for high tract disease) though the fistula attempts to bring together and close the tract, passing out at opening of the perianal skin adjacent to the external opening


What causes anorectal abscesses? 

  • Caused by plugging of the anal ducts, the ducts that drain the anal glands in the anal wall, helping to ease the passage of faecal matter through mucus secretion.
  • Blockage -> fluid stasis -> infection
  • Common causative organisms include E. coli, Bacteriodes spp., and Enterococcus spp..


How are anorectal abscesses managed? 

  • Conservative: analgesia + abx 
  • Surgical: surgical incision and drainage. These can then be left to heal via secondary intention
  • Proctoscopy post drainage to check for perianal fistula 


What is an anal fissure? 

  • Tear in the mucosal lining of the anal canal, most commonly due to trauma from defecation of hard stool.
  • It can be classified according to its duration:
    • Acute – present for <6 weeks
    • Chronic – present for >6 weeks


What are the symptoms of anal fissure? 

  • Intense pain post-defecation, which can last several hours.
  • Pain can be far out of proportion to the size of the fissure
  • Other sx: may include bleeding (commonly bright red blood on wiping) or itching, both typically post-defecation.


How would you examine? 

  • DRE - palpation
  • EUA - examination under anaesthetic
  • Proctoscopy


How are anal fissures managed? 

  • Conservative: reducing RFs, analgesia
    • Increasing fibre and fluid
    • Stool softening laxatives: (e.g. Movicol or Lactulose)
    • Topic anaesthetics: e.g. lidocaine
    • Hot baths can to relax the anal sphincter
  • Medical: GTN cream or diltiazem cream
  • Surgical therapy (for chronic fissures)
    • Botox injections
    • Lateral sphincterotomy 


What is a rectal prolapse? 

  • Protrusion of mucosal or full-thickness layer of rectal tissue out of the anus.
  • There are two main types* of rectal prolapse:
    • Partial thickness – the rectal mucosa protrudes out of the anus
    • Full thickness – the rectal wall protrudes out the anus


What are the clinical features of a rectal prolapse? 

  • Rectal mucus discharge
  • Faecal incontinence
  • Per rectum bleeding
  • Visible ulceration


What are the surgical management options? 


  • Perineal approach
    • Delormes operation: the prolapsed lining of the rectal mucosa is removed and the underlying muscle reinforced with plicated sutures
    • Altemeier’s operation: resection of the redundant prolapsed bowel to restore the original anatomy
  • Abdominal approach: laparoscopically (most common), robotically, open


What are the majority of anal cancers? 

  • Squamous cell carcinomas: Below the dentate line
  • Remainder (~10%): adenocarcinomas - upper anal canal epithelium and the crypt glands


What is anal intraepithelia neoplasia? 

  • Precancerous condition that can affect either the perianal skin or anal canal, linked to the development of squamous cell carcinoma.
  • Strongly linked to infection with the human papilloma virus (HPV).
  • The grading of AIN is dependent on the degree of cytological atypia and the depth of that atypia in the epidermis. High-grade AIN (grade 2 or 3) is premalignant and may progress to invasive cancer.


What are the RFs for developing anal cancer? 

  • HPV infection ( 80-90% of cases, especially HPV-16 and HPV-18)
  • HIV/ syphilus
  • Increasing age
  • Smoking
  • Immunosuppression
  • Crohn’s disease


What are the symptoms of anal cancer? 

  • Rectal pain or rectal bleeding
  • Anal discharge
  • Pruritus
  • Presence of a palpable mass
  • Locally invasive disease: Perianal infection and fistula-in-ano 


How is anal cancer investigated? 

  • Gold standard: proctoscopy
  • Examination under anaesthetic (EUA) + biopsy 
  • Women: a smear test to exclude CIN +  further biopsies if signs of vulval intraepithelial neoplasia (VIN) are present.
  • HIV test
  • Imaging
    • USS-guided Fine Needle Aspiration (FNA): of any palpable inguinal lymph nodes
    • CT thorax-abdomen-pelvis: distant metastases
    • MRI Pelvis: to assess the extent of local invasion (T stage)


How is anal cancer managed? 

What are some of the complications of this treatment? 

  • 1st line: chemo-radiotherapy
    • Treatment via external beam radiotherapy to the anal canal and inguinal lymph nodes
    • Dual-chemotherapy agents, such as mitomycin C and 5-fluorouracil.
  • Surgery: for advanced disease 
    • Abdominoperineal resection (APR) mainly
    • For some a posterior or total pelvic exenteration is required.
  • Follow up: every 3–6 months for a period of 2 years


  • Chemoradiation-related pelvic toxicity: can present with dermatitis, diarrhoea, proctitis, and/or cystitis.
  • Longer term: fertility issues, faecal incontinence, vaginal dryness, erectile dysfunction, and rectovaginal fistula