UGI/CR - Anus and Rectum Flashcards by Izzy Burns

DDx - child rectal bleed

Constipation /poor diet
Anal fissure 
Juvenile polyp 
Haemorrhoids 
IBD 
NAI
Trauma
Surgical causes - intussusception, volvulus etc

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5 most common causes of infective bloody diarrhoea

Noravirus
Rotavirus
Camplobacter 
Shigella 
salmonella

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PS Rectal cancer

Bright red PR bleed
Tenesmus
PR - mass? +/- mucus

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PS Anal cancer

Bleeding 
Pain 
Changes in bowel habit 
pruritis ani 
Masses 
Stricture

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Where is the anal canal from?

Superior aspect of pelbic diaphragm –> anus

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What is the internal anal sphincter?

Involuntary sphincter surrounding upper 2/3 anal canal

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What is tonic contraction of the internal anal sphincter stimulated by?

Sympathetic fibres from superior rectal/hypogastric plexus

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Role of parasympathetic fibres on the internal anal sphincter

Inhibit tonic contraction

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Where is the external anal sphincter

Lower 2/3 anal canal

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Is the external anal sphincter under voluntary or involuntary control

Voluntary control

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Which nn mediates the external anal sphincter?

Inferior rectal nn

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What is a haemorrhoids

Disrupted/dilated anal cushions

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Where are internal haemorrhoids

Above the dentate line

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Where are external haemorrhoids

Below dentate line

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Position of haemorrhoids

3,7,11 oclock (when view from lithotomy position)

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Why do haemorrhoids arise?

Because of breakdown of SM layer, muscularis mucosae

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Aetiology haemorrhoids (3)

Idiopathic
Incr anal tone (e.g. chronic constipation)
Factors –> congestion superior rectal

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Factors causing congestion of superior rectal vv (4)

Cardiac failure
Pregnancy
Rectal carcinoma
Any raised IAP

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Where does the superior rectal vein drain?

Inferior mesenteric vv

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Where does the inferior = middle rectal veins drain?

Cavally

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Link between haemorrhoids and anal rectal varices

Anastomoses of anal cushions = portal-caval anastomoses
Anal-rectal varices can co-exist w/ haemorroids in pt w/ portal HTN
Haemorrhoids most commonly arise in abscence of portal HTN

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1st degree haemorrhoids

Confined to anal canal

Bleed but don’t prolapse

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2nd degree haemorrhoids

Prolapse on defecation

Then reduce spontaneously

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3rd degree haemorrhoids

Prolapse outside anal margin on defecation

May be manually reduced

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4th degree haemorrhoids

Remain prolapsed outside anal margin at all times

Sx haemorrhoids (5)

``` Bright red rectal bleed Prolapse Mucous discharge Pruritis ani Painful if piles becomes thrombosed/prolapse ```

Complications haemorrhoids

Anaemia | Thrombosis

How long does it take thrombosed haemorrhoids to fibrose?

2-3w

Mx of thrombosed haemorrhoids

Conservative Cold compresses Opioids Rest

ix Haemorrhoids (4)

Abdo exam PR Proctoscopy/rigid sigmoidoscopy Colonoscopy/flexi-sigmoidoscopy

Conservative mx haemorrhoids (4)

``` Consume plenty fl Try not to strain TO analgesia/astringments Bulk forming laxative Anti-inflammatory creams ```

Non-conservative Mx haemorrhoids

Sclerotherapy | Banding + suction

What is Sclerotherapy

5% phenol + almond oil into each pile

What degree piles can be treated with sclerotherapy

1st/2nd degree only

How often must sclerothearpy be performed?

Monthly

SE sclerothearpy (3)

Pain Prostatitis Infection

What degree piles can Banding and suction be used for?

1st - 3rd

Where must Banding + suction be positioned?

Above the dentate line

What degree haemorrhoids is surgery used on

3rd + 4th degree

Types of surgery used for piles Mx

Stapled haemorrhoidopexy | Haemorrhoidal aa ligation (HALO)

What is a perianal haematoma?

Thrombosed external pile

Why is a perianal haematoma painful?

Because it is covered by squamous epithelium + nerves

PS perianal haematoma

Sudden pain + lump on anal verge | Lump is tense, smooth, dark-blue, cherry sized

Mx perianal haematoma in acute phase

Drain under LA

Role of anal sinuses/crypts

Release mucous when compressed by faeces

What are anorectal abscesses usually caused by?

Gut organisms | --> fistula

What conditions are anorectal abscesses associated with? (5)

``` Chrons Malignancy TB UC DM ```

PS Anorectal abscess (2)

Painful tender swellings | Constant discharge

Mx Anorectal abscess

Incision + drainage under GA + seton

What is a pilonoidal sinus?

Obstruction of natal cleft hair follicles 6cm above the anus --> abscess formation w/ foul discharge

Who gets pilonoidal sinus?

Obese males

Mx pilonoidal sinus

Incision of sinus tract 1' closure Pre-op Abx Hygiene + hair removal advice given

Diagnostic tests perianal warts

Operative exploration | Or MRI

Ix if suspect higher up sepsis in peri-anal wart s

EAU

Def fistula in ano

A track that communicates between the skin + anal canal/rectum

Aetiology fistula in ano

``` TB Chrons Diverticular disease Rectal carcinoma ICC ```

Ix fistula in ano

Exam under anaesthetic EAU (Endoanal USS) MRI

What does Goodsalls rules relate to?

Relates external opening of an anal fistula to the internal opening

Goodsalls rules - Posterior fistulas

Curved track w/ opening in the posterior midline

Goodsalls rules - anterior fistulas

Direct opening into the anal cavity

Mx of superficial low level distula in ano

Laid open to heal by fistulotomy

Mx of high fistula

Injcted w/ fibrin glue/fistula plug + dries up

Use of Seton suture in fistula Mx

Gradually tightened over time to maintain continence

Med Mx recurrent fistulae/Chrons fistula

Metronidazole

What is an Anal fissure

A tear in the sensitive anal canal distal to the dentate line, producing pain on defecation.

Which gender mostly gets anal fissures

Males

RK Anal fissures (5)

``` Constipation Chrons disease Anorectal infection (TB/HIV) STIs (herpes/syphilis) Haematological malig ```

Sx Anal fissure (5)

``` Sharp burning pain, worse on defecation Then dull ache lasting for hrs Assoc constipation pruritis ani bleeding on defecation ```

o/e anal fissure (3)

``` Midline longitudinal tear in rectal mucosa Sentinal pile (ext) PR not poss b/c pain + sphincter spasm ```

Ix Anal fissure

Proctoscopy + Sigmoidoscopy under GA | To exclude other disease

Mx Anal fissure - conservative (3)

Small may heal spont LLA + LUbe - Sx relief Fl/fibre/bulk-laxative

Med Mx Anal fissure

0.4% GTN cream (relaxes sphincter) | Botulinum toxin injection (lasts 8w)

Mx of Intractable anal fissure

Lateral sphincterotomy under GA

UGI/CR - Anus and Rectum Flashcards

(73 cards)