Perianal Conditions Flashcards
(31 cards)
What are haemorrhoids?
Prolapsed vascular cushions (connective tissue and blood vessel networks) with sensory function involved in continence (bowel contents above are solid, liquid, or gas - is it safe to pass flatus?)
3 in total at 3, 7, and 11 o’clock (mucosa and submucosa)
Describe the aetiology of haemorrhoids.
Uncommon >20yrs Poor diet (low fibre, dehydrated) ---> constipation ---> straining ---> shearing forces and congestion/enlargement of vascular cushions ---> haemorrhoids bleed
What is the presentation of haemorrhoids?
- discomfort
- pruritus due to perianal discomfort + mucous discharge
- rectal bleeding = bright red, after defecation, amount varies
- prolapse during/after defecation = swelling noticed on wiping, may need to be pushed back in
What is the classification of haemorrhoids?
Internal or external
1 = bleed but do not prolapse 2 = prolapse but reduce spontaneously 3 = prolapse and require reduction 4 = prolapse and are irreducible (causing continence problems)
What is found on examination of haemorrhoids?
1st/2nd = cannot be palpated in DRE; visible on protoscope as darker blue/red mucosa bulging into end of instrument with a loss of longitudinal corrugations and three deep clefts between haemorrhoids
3rd = permanently prolapsed; mucosal covering is soft, smooth, and exudes mucus; associated with skin tags; ulcerate and bleed
Thrombosed = haemorrhoid becomes tense, hard, and oedematous —> painful defecation
note: differentiate between thrombosed haemorrhoids and perianal haematomas (covered by skin)
What investigations are appropriate in haemorrhoids?
- protoscopy
- sigmoidoscopy = exclude bowel cancer, IBD; severe symptoms e.g. severe, dark bleeding; FHx; other symptoms e.g. diarrhoea
- colonscopy if anaemia is present
What is management of haemorrhoids?
Conservative:
- diet
- increased fluid intake
- cold compress
Medical:
- creams
- stool softeners
- lignocaine
Surgical:
- banding: routine, outpatient, painless if banded above dentate line
- injection
- haemorrhoid arterial ligation operation (HALO)
- haemorrhoidectomy: painful but effective
Define fissure-in-ano.
Anal fissure. Longitudinal split (ulcer) in the skin of the anal canal.
Acute tear common in constipation (usually heals quickly)
Defecation reopens tear —> pain —> increased anal sphincter tone —> spasm —> reduced blood supply —> reduced healing —> tear more likely to reopen —> cycle of tearing, pain, and spasm —> base becomes fibrous and does not heal —> chronic ulcer of anal verge
Describe the aetiology of fissure-in-ano.
Young males and after childbirth
Common in children (pass bulky stools quickly)
What is the presentation of fissure-in-ano?
- very painful during defecation (tearing) —> chronic fissure has pain persisting for hrs —> patient afraid to defecate —> large, hard faeces —> pain worse on next defecation and harder to pass (worse spasm)
- rectal bleeding
- may be periods of remission (fissure heals or becomes chronic)
What are the examination findings in fissure-in-ano?
- majority in pos. midline (esp. males) but may be in ant. midline (female)
- small skin tag may be visible at lower end of fissure
- exquisitely tender anal sphincter
What are the appropriate investigations in fissue-in-ano?
Protoscopy/sigmoidoscopy under general anaesthesia
What is the management of fissure-in-ano?
80% improve on own
Conservative: diet, stool softeners
Medical: GTN cream, diltiazem (reduced anal tone increases blood supply), botox (temporarily relax internal anal sphincter)
Surgical: lateral sphincterotomy (contraindicated in females - shorter anal sphincter and increased risk of injury during childbirth/atrophy during menopause)
Define an ano-rectal abscess.
Infection begins in anal gland and tracks down (peri-anal abscess) or penertrates external anal sphincter (ischio-rectal abscess)
Peri-anal abscess: swelling is clearly at anal margins, which it distorts
Ischio-rectal abscess: lies lateral to anus, occupies a much larger space and can track around behind the anus to the opposite side
Abscess in intersphincteric space
Abscess in submucosa of anus
Describe the aetiology of an ano-rectal abscess.
Occur in all ages but more common at 20-50yrs
More common in males
What is the presentation of ano-rectal abscesses?
- gradual (days) onset of severe, throbbing pain which makes moving and defecation painful (worse with perianal abscesses - confined space so cannot expand)
- tender swelling close to anus
- abscess will burst if untreated
- systemic (sepsis): malaise, anorexia, sweating, rigors
What are the examination findings in ano-rectal abscesses?
- patient tries not to move and lies on their side
- tachycardia
- pyrexia/sweating
- dry, furred tongue
- fetor oris (halitosis)
- scarring from previous fistulae/abscesses
- cellulitis and necrotising fasciitis may occur
- tender red mass lateral to anus in soft tissue between anus and ischial tuberosity
- inguinal lymphn nodes may be enlarged/tender
- DRE (under anaesthesia): abscess bulges into side of lower rectum
What is the management of ano-rectal abscesses?
Anaesthetise to examine and drain
Reminder: what is a fistula?
Punctum
Pathological tract lined with epithelium/granulation tissue that connects two epithelial surfaces
Define fistula-in-ano.
Fistula connecting lumen of rectum/anal canal with external perianal skin.
Caused by abscess developing in anal crypt gland in the intersphincteric space that bursts in two directions: internally into anal canal and externally through the skin.
Mucus forced through fistulous tract as stool expelled (prevents fistula healing)
Associated with Crohn’s/UC
Can be caused by direct infiltration and necrosis of low rectal carcinoma.
What is the classification of fistula-in-ano?
LOW:
- opening below ano-rectal ring
- no significant incontinence
HIGH:
- opening above ano-rectal ring
- dividing would cause incontinence
Ano-rectal ring: puborectalis fuses with external sphincter (maintains continence)
What is the presentation of fistula-in-ano?
- Hx of perianal abscess which spontaneously burst/drained surgically
- watery/purulent/bloodstained discharge from external opening of fistula —> pruritus ani
- recurrent episodes of pain if pus collects in fistulous tract
- may appear to heal, but becomes painful and discharges again
- IBD S&S
What is Goodsall’s rule?
Internal opening of an ant. fistula lies along a radial line drawn from the external opening to the anus.
Internal opening of a pos. fistula always lies in the midline posteriorly.
What are the examination findings in fistula-in-ano?
- external opening(s) of fistula visible as puckered scar/small tuft of granulation tissue anywhere around the anus (usually close to anal verge)
- external opening of fistula not usually painful, but surrounding tissue may be thickened and tender
- DRE: internal opening of fistula may be felt as an area of induration/small nodule beneath mucosa (can determine if it is low or high) and indurated tract may be palpable under anaesthesia
