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Year 3 - Surgery > 3.05 General Surgery - Anorectal Disease > Flashcards

3.05 General Surgery - Anorectal Disease Flashcards

1
Q

What are haemorrhoids?

A

Abnormal swellings or enlargements of the anal vascular cushions, whose role are to assist in maintaining continence.

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2
Q

What are the risk factors for haemorrhoids?

A
  • excessive straining (e.g. chronic constipation)
  • increasing age
  • raised intra-abdominal pressure (e.g. pregnancy, chronic cough)
  • family history
  • cardiac failure
  • portal hypertension
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3
Q

What are the clinical features of haemorrhoids?

A
  • painless, bright red rectal bleeding
  • pruritus
  • rectal fullness
  • soiling

OE normal unless haemorrhoids have prolapsed.

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4
Q

What are the differentials for haemorrhoids?

A
  • malignancy
  • IBD
  • diverticular disease
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5
Q

How are haemorrhoids typically investigated?

A

Proctoscopy can be used to confirm diagnosis.

Any significant or prolonged bleeding warrant FBC and clotting screen.

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6
Q

How are haemorrhoids treated?

A

Mostly conservatively by increasing daily fibre and fluid intake, prescribing laxatives, and prescribing topic analgesia.

Surgical option is haemorrhoidal artery ligation first line.

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7
Q

What is rectal prolapse?

A

Protrusion of mucosal (partial thickness) or full thickness layer of rectal tissue out of the anus.

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8
Q

What are the risk factors for pelvic prolapse?

A
  • increasing age
  • female gender
  • multiple deliveries
  • straining
  • anorexia
  • previous traumatic vaginal delivery
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9
Q

What are the clinical features of rectal prolapse?

A
  • rectal mucus discharge
  • faecal incontinence
  • rectal bleeding
  • rectal fullness
  • tenesmus

OE prolapse not always evident, but can be identified by asking the patient to strain. DRE will elicite a weakened anal sphincter.

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10
Q

How is anal prolapse managed?

A

Surgical repair by perineal or abdominal approach is only definitive management.

Conservative management may be used for those unfit for surgery, and includes increasing dietary fibre and fluid intake.

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11
Q

What is an anal fissure?

A

A tear in the mucosal lining of the anal canal, most commonly secondary to trauma from defecation of hard stool.

Acute <6/52

Chronic >6/52

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12
Q

What are the risk factors for anal fissure?

A
  • constipation
  • dehydration
  • IBD
  • chronic diarrhoea
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13
Q

What are the clinical features of anal fissures?

A
  • intense pain post-defecation
  • bleeding
  • itching

OE fissures may be visible and palpable; DRE will be refused due to pain so EUA may be necessary.

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14
Q

What are the differentials for anal fissures?

A
  • haemorrhoids
  • Crohn’s disease
  • ulcerative colitis
  • anal cancer
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15
Q

What is the medical management of anal fissures?

A

Reducing risk factors:
- increase fibre and fluid intake
- stool softening laxatives (e.g. Movicol)
- topic anaesthetics
- GTN cream*

*GTN cream increased blood supply to region and relaxes internal anal sphincter, putting less pressure on the fissure, therefore promoting healing and reducing pain.

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16
Q

What is the surgical management of anal fissures?

A

Reserved for chronic fissures.

Botox injections to the internal anal sphincter.

Lateral sphincterotomy can be performed.

17
Q

What is a perianal fistula?

A

An abnormal connection between the anal canal and the perianal skin.

18
Q

What are the causes of a perianal fistula?

A
  • anorectal abscess
  • IBD
  • diabetes mellitus
  • history of trauma to the anal region
  • previous radiation therapy
19
Q

What are the clinical features of anal fistulas?

A
  • perianal abscess
  • discharge onto the perineum (blood, mucus, pus, faeces)

OE external opening on the perineum

20
Q

How is a perianal fistula investigated?

A

MRI imaging

21
Q

How is perianal fistula managed?

A

Definitive surgical management depends on cause and site.

Fistulotomy or placement of a seton.

22
Q

What is the pathophysiology of anorectal abscesses?

A

Plugging of the anal ducts resulting in fluid stasis, leading to infection, most commonly by E. coli.

23
Q

What are the clinical features of an anorectal abscess?

A
  • severe pain in perianal region
  • perianal discharge
  • systemic features (including sepsis)

OE erythematous, fluctuant and tender perianal mass. Severe tenderness on PR examination.

24
Q

How is anorectal abscess investigated?

A

Diagnosis usually clinical but surgical management required.

Routine bloods (FBCs, U&Es, clotting, Group and Save)

25
Q

How are anorectal abscesses managed?

A
  • antibiotic therapy
  • sufficient analgesia
  • EUA rectum and incision and drainage of abscess
26
Q

What are the most common subtypes of anal cancer occuring

a) above the dentate line

b) below the dentate line

b) pre-cancerous

A

a) adenocarcinomas

b) squamous cell carcinomas

c) anal intraepithelial neoplasia (AIN)

27
Q

What are the risk factors for anal cancer?

A
  • HPV infection
  • HIV infection
  • increasing age
  • immunosuppression
  • Crohn’s disease
28
Q

What are the clinical features of anal cancer?

A
  • rectal pain
  • rectal bleeding
  • anal discharge
  • pruritis
  • palpable mass
  • tenesmus
  • faecal incontinence

OE ulceration and mass on PR examination. Inguinal lymph nodes raised.

29
Q

Outline the lymphatic draining of the anus

a) above the dentate line

b) below the dentate line

A

a) mesorectal, para-aortic and paravertebral nodes

b) superficial inguinal lymph nodes

30
Q

What are the differential diagnoses for anal cancer?

A
  • haemorrhoids
  • anal fissure
  • anal warts
  • low rectal cancer
31
Q

How is anal cancer investigated?

A
  • protoscopy
  • EUA and biopsy

Staging using USS FNA of palpable inguinal lymph nodes; CT TAP for distant metastases; MRI pelvis to assess extent of local invasion.

32
Q

How is anal cancer managed?

A
  • chemoradiotherapy
  • surgical excision (abdominoperineal resection)

Year 3 - Surgery (30 decks)

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