Perianal disease

Question 1

What is the dentate line

Answer 1

When the mucosa gathers into longitudinal folds which contain anal glands (Secrete mucus)

Question 2

What is above the dentate line derived from

Answer 2

Embryological hindgut

Question 3

What is below the dentate line derived from

Answer 3

Ectoderm

Question 4

What is the epithelium above the dentate line

Answer 4

Columnar epithelium

Question 5

What is the epithelium below the dentate line

Answer 5

Non keratinising squamous epithelium

Question 6

What is the epithelium in the anal verge

Answer 6

Keratinizing squamous epithelium

Question 7

Blood supply above dentate line

Answer 7

Superior rectal artery/vein (derived from IMA)

Question 8

Blood supply below dentate line

Answer 8

Inferior rectal artery/vein (derived from internal pudendal artery)

Question 9

Lymphs above dentate line

Answer 9

Internal iliac lymph nodes

Question 10

Lymphs below dentate

Answer 10

Superficial inguinal lymph nodes

Question 11

Nervous innervation above dentate line and presentation

Answer 11

Inferior hyper gastric plexus (stretch ulnae)

Question 12

Nervous innervation below dentate line and presentation

Answer 12

Pudendal nerve (pain, temp, touch and pressure)

Question 13

Lications of anal cushions

Answer 13

3 o clock
7 o clock
11 o’clock

Question 14

What is a haemorrhoid

Answer 14

Abnormal swelling and vascular engorgement of normal anal cushions

Question 15

Investigations with presentations

Answer 15

DRE exam

Protoscopy (for internal haemorrhoids)

Question 16

What is a anal fissure

Answer 16

Longitudinal tear in the anal canal mucosa

Question 17

Where do anal fissures usually present

Answer 17

6 o’clock

12 oclock

Question 18

What are anal fissures associated with

Answer 18

Constipation

Crohns

Question 19

Symptoms of anal fissures

Answer 19

Severe pain post defecation
Fresh red bleeding
Itching
PR excruciation

Question 20

Exam findings of anal fissure

Answer 20

Break or ulcer in the mucosa

Question 21

Acute management of anal fissure

Answer 21

Dietery modification

Laxatives, instillagel and topical diltiazem or GTN cream

Question 22

Chronic management of anal fissure

Answer 22

Examination under anaesthesia and injection of botox (relaxes)

Lateral sphincterotomy

Question 23

What is a peri anal abscess

Answer 23

Collection of pus in anal region

Question 24

Pathology of peri anal abscess

Answer 24

Cyryptoglandular infection

Bacterial overgrowth

Usually e.coli, bactericides spp. And enterococcus spp

Question 25

Presentation of perianal abscess

Answer 25

Painful, hot, red lump in perianal region Discharging pf pus Sepsis

Question 26

What investigations may some patients require with PA abscess

Answer 26

CT or MRI

Question 27

Management of perianal abscess

Answer 27

surgical incision and drainage of abscess Antibiotics not good because can't penetrate into it

Question 28

What is a fistula in and

Answer 28

Abnormal connection between the anal canal and peri-anal skin

Question 29

Risk factors of fistula in ano

Answer 29

IBS Systematic disease - HIV, TB, diabetes Trauma Pelvic radiation

Question 30

Presentation of fistula in ano

Answer 30

Peri-anal abscess | Intermittent or continuous discharge of pus, blood or mucuous from the perineum

Question 31

On examination of fistula in ano

Answer 31

Small opening in perineum Some granulation tissue that may discharge on palpation Thickening fibrous tract palpable in the skin

Question 32

What is the Goodsall's rule

Answer 32

Where the fistula is decides on treatment e.g. If patient lying down and you drew a line going through middle of the anus going horizontally- - External opening above (anterior) to the line is connected through the internal opening by a short straight line - External opening below (posterior) to the line has a curved or horseshoe tract

Question 33

Investigation of a fistula in ano

Answer 33

Exam using proctoscopy or exam under anaesthesia Curved tracts usually get gluteal or pelvic MRI

Question 34

Managemt of fistula in ano

Answer 34

Drain abscess Seton- an elastic band put through external opening into internal opening and tied to make a loop that allows sepsis to drain, preventing abscess. Fistulotomy- laying open of the tract including the overlying skin and/or muscle.