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anal and perianal disorders Flashcards

1
Q

how are anal fissures diagnosed?

A

direct visualisation
tear in skin

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2
Q

which age are fissures most common

A

common across lifetime - more common in 20s-40s

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3
Q

what can cause anal fissures?

A
  • Tearing from passage of hard stools  constipation
  • Anal trauma – sex, surgery
  • Drugs – chemo, opioids, nicorandil (vasodilator  used for angina)
  • Secondary: IBD, STIs
  • Dermatology: psoriasis, eczema, pruritis ani)
  • Pregnancy/ childbirth
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4
Q

what are the symptoms of anal fissures?

A

localised pain on defection – sharp, can be persistent, tearing sensation
- Bleeding: small amount of fresh blood on wiping

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5
Q

what types of management is used for anal fissures?

A
  • Lifestyle: keep stools soft and easy to pass (more fibre, water). Anal hygiene, avoid straining or stool withholding
  • Analgesia: paracetamol ± NSAID, warm bath, avoid opioids (causing constipation)
  • Topical agents: short course of 5% lidocaine ointment can be applied prior to defecation. GTN ointment can be applied BD  headache side effects
  • Surgical:
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6
Q

what are the surgical managements of anal fissures?

A

: most commonly lateral internal sphincterotomy, botox, anal advancement flap

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7
Q

what are haemorrhoids?

A

Abnormally swollen vascular cushions that are located in the anal canal.

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8
Q

when is it most common to get haemorrhoids across lifetime?

A

about 11% in general population with equal sex prevalence and peak between 45-65

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9
Q

what are internal haemorrhoids?

A

located proximal to dentate line

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10
Q

what are external haemorrhoids?

A

distal to dentate line

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11
Q

describe a grade 1 internal haemorrhoid

A
  • Grade1: no prolapse, prominent blood vessels
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12
Q

describe a grade 2 internal haemorrhoid

A
  • Grade2: prolapse upon bearing down but spontaneous reduction
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13
Q

describe a grade 3 internal haemorrhoid

A
  • Grade 3: prolapse upon bearing down requiring manual reduction
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14
Q

describe a grade 4 internal haemorrhoid

A
  • Grade 4: prolapse with inability to be manually reduced
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15
Q

what is the dentate line?

A

divides upper 2/3 of anal canal with lower 1/3

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16
Q

what type of cells are the upper 2/3 of rectum made up of?

A

rectal columnar epithelium

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17
Q

what is the histology of lower 1/3 of rectum?

A

stratified squamous epithelium

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18
Q

why do haemorrhoids become so itchy?

A
  • Lower: stratified squamous epithelium  highly innervated hence highly itchy
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19
Q

what is the aetiology of haemorrhoids??

A

Aetiology: symptomatic haemorrhoids thought to develop with supporting tissue with anal cushions deteriorate
- Deterioration in connective tissue
- Increases internal anal sphincter tone
- Dilation of arteriovenous anastomoses within anal cushions
- Dilation of veins within the haemorrhoidal venous plexus

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20
Q

what are RF of haemorrhoids?

A

constipation and prolonged straining
- Diarrhoea, pregnancy, increased age, prolonged sitting, anticoag use and pelvic tumours

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21
Q

what symptoms are seen with haemorrhoids?

A
  • Perianal irritation
  • Bright red rectal bleeding
  • Faecal incontinence: often mild due to prolapse of haemorrhoids and subsequent leakage
  • Mucous discharge: due to internal haemorrhoids covered with columunar epithelium
  • Fullness in perinanal area
  • Pain: overt pain is uncommon unless there is strangulated haemorrhoid or thrombrosis of haemorrhoid
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22
Q

what would a normal DRE examination show with haemorrhoids?

A

non -prolapsed internal haemorrhoids

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23
Q

how would prolapsed haemorrhoids present O/E?

A

: blue ish, bulging lesion on straining

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24
Q

how would external haemorrhoids present O/E?

A

blue ish bulging lesion

25
how would thrombosed haemorrhoids present?
if acute it will be very painful, purplish, oedematous perianal mass
26
how would you non medicinally manage haemorrhoids?
- Healthy lifestyle: sufficient water intake, high fibre to prevent constipation, undertaking physical activity - Toilet training: adopt correct positioning during defaecation, avoid straining and prolonged periods on toilet - Avoid medications causing constipation
27
how would you pharmacologically manage haemorrhoids?
- Laxatives: may help reduce constipation and reduce bleeding - Analgesia: NSAIDS and non-opioid therapies - Topical agents: anaesthetic and steroids - Venoactive agents: phelbotonics  increase venous tone and reduce bleeding and help with other perianal symptoms such as irritation (flavonoids and calcium dobesilate) - Antispasmodics: reduce anal sphincter spasms that may cause perianal symptoms  mainly used in those with anal fissures
28
what are some of the surgical options for haemorrhoids?
rubber ligation sclerotherapy infrared coagulation haemorrhoidectomy
29
describe rubber band ligation
rubber band at base of haemorrhoid to stop blood flow (grade 1-3 internal)
30
what is sclerotherapy?
injection of sclerosant agent into internal haemorrhoid  inflame reaction to destroy submucosal tissue (grade I-II internal haemorrhoid)
31
how is infrared coagulation used within haemorrhoid surgical management?
- Infrared coagulation: infrared light direct to haemorrhoid tissue (grade I – II)
32
what is a haemorrhoidectomy?
surgical removing haemorrhoids
33
what are complications of haemorrhoidectomy?
complications can include bleeding, faecal incontinence and anal stricture
34
what are risk factors for perianal abscesses?
fistula – in- ano - IBD, DM and immunosuppression
35
what are symptoms of perianal abscesses?
Symptoms: typically pain and swelling in peri-anal region - Sepsis features - Malaise
36
what are signs of perinanal abscesses?
Signs: - Fluctuant, tender perianal swelling - Pus discharge - Erythema - Fever
37
what is the management of perianal abscesses?
Management: incision and drainage  cut into abscess and drain pai and packed with gauze like material (prevents cavity closing over and pus reaccumulating
38
what is fistual- in-ano?
fistula are tracts that form between blocked internal gland and skin
39
how would a fistula-in-ano present?
- Presents with pain, discharge, skin irritation and can have bleeding - Usually follow abscesses in Chrons, diverticulitis, hidradenitis supprartive (HS), TB< HIV, post-colorectal surgery
40
what are the surgical options of fistula- in-ano options?
setons advancement flap procedure LIFT endoscopic ablation fibrin glue bioprosthetic plug
41
what do setons do?
: surgical thread to help drain sndf heal and progressively tighter ones to slowly cut through fistula in ano
42
what is an advancement flpa procedure?
cutting fistula and covering hole with flap of tissue from inside rectum
43
what LIFT with fistula-in-ano surgery?
cut made above fistula and sphincter muscles pulled apart – fistula sealed at both ends
44
what is endoscopic ablation within fistula - in ano?
- Endoscopic ablation: tiny endoscope inserted into fistula and electrode passed through to seal (similar to laser surgery)
45
how does a bioprosthetic plug work?
made from animal tissue and blocks internal opening of fistula
46
what is hidradentitis suppurativa also known as?
acne inversus
47
what is hidradenitis suppurative (HS)?
- Chronic inflammatory skin conditions with lesions including deep seated nodules and abscesses, draining tracts and fibrotic scars
48
what would an unexplained anal mass or unexplained anal ulceration indicate?
anal cancer
49
what is proctalgia fugax?
a benign anal pain syndrome
50
what is the aetiology of proctalgia fugax?
potentially due to spasm of muscles, could be anal sphincter or pelvic floor muscles
51
what are symptoms of proctalgia fugax?
recurrent severe cramping pain, usually at night - Attacks are so rare so pain management/ drug therapies are not beneficial - Physio can help and re train muscles
52
what is pruiritis ani?
bum itchiness
53
who is more affected in pruritis ani?
men more than women mainly aged 40-60
54
what is the aetiology of pruiritis ani? ,
- 50% are caused by dermatological cause: psoriasis, dermatitis, skin tags, lichen sclerosus ( rare skin disease causing itchy and painful patches of thin, white, wrinkled-looking skin) - Parasites: threadworm (paeds/ people around kids), scabies, viral, bacterial, fungal infections including STIs - Anal/ colerectal cancer, piles, fissures, fistulas, incontinence, chronic diarrhoea - DM, anaemia, leukaemias, thyroid problems, liver disease - Medications: steroids, colchicine, Abx, immunosuppressants
55
what is proctitis?
: pain and inflammation of the last 6in of rectum
56
what are symptoms of proctitis?
faecal urgency, diarrhoea, constipation, tenesmus (needing to poo but can not), mucus on stool, PR bleeding, pus PR
57
what are the RF of proctitis?
: in those practicing receptive anal intercourse - either result of IBD or infections including STI
58

GI (12 decks)

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