Anal canal diseases Flashcards
What are the causes of anal fissures?
- chronic constipation with passage of hard mass
- dragging of the mucosa by a prolapsed pile
- traumatic tearing by an enema nozzle, or large anal speculum
What are the common locations for an anal fissure to occur?
- mid-posterior point (90%)
- mid-anterior (10%)
What is the difference between acute & chronic anal fissure?
ACUTE CHRONIC
- no fibrosis - fibrosis
- superficial - deep
- mobile - fixed
- internal sphincter spastic - fibroses sphincter
- no piles - piles
What are the local symptoms of anal fissures?
- severe pain at defecation
- bleeding within or after defecation
- anal discharge -> pruritis -> itching
- pruritis
- constipation
What are the reflex symptoms of anal fissures?
- bladder: dysuria -> retention
- GYN: dysmenorrhea & dyspareunia
- back pain sometimes referred to posterior aspect of thighs
What are the signs of anal fissures?
- acute anal fissure is seen
- chronic anal fissure is felt
- > elongated indurated ulcer
- > sentinel pile
- > fibroid internal sphincter
- > hypertrophied papilla
What are the complications of anal fissures?
- chronicity
- abscess
- perianal or submucous fistula
- pruritis ani & eczema of perineal skin
How should acute anal fissures be treated?
- high fiber diet & laxatives
- local anesthetic ointment (lignocaine)
- glyceryl trinitrate ointment -> gives headaches
- warm bath for 10 - 15 minutes (Sitz bath)
How is a chronic anal fissure treated?
lateral internal sphincterotomy operation
What is the difference between internal & external hemorrhoids?
INTERNAL EXTERNAL
- lower rectum upper anal canal - lower anal canal
- columnar epithelium - skin
- varicosity of internal hemorrhoidal plexus - external hemorrhoidal plexus
What are the causes of secondary piles?
- congestive heart failure or constrictive pericarditis
- liver cirrhosis & portal hypertension
- pregnancy
- fibroid
- retroperitoneal sarcoma
- carcinoma of the rectum
What are the precipitating factors of primary piles?
- stricture urethra
- chronic constipation
- prolonged standing
What are the number & position of piles?
determined by the superior rectal artery
- right anterior -> 11 o’clock
- right posterior -> 7 o’clock
- left lateral -> 3 o’clock
What is the clinical picture of hemorrhoids?
- bleeding per rectum -> fresh bright
- prolapse
- discharge
- pruritis ani
- pain if complicated
- secondary anemia
What is used for rectal examination of piles?
- proctoscopy
- sigmoidoscopy
What are the complications of hemorrhoids?
GENERAL
- secondary anemia
- portal pyemia
LOCAL
- bleeding
- prolapse
- thrombosis of prolapsed pile due to sphincteric spasm (surgery within 24hrs)
- infection -> perianal suppuration & sloughing
- ulceration
- fibrosis
- anal fissure due to traction
How are hemorrhoids/piles graded?
GRADE I -> no protrusion
GRADE II -> protrusion with spontaneous reduction
GRADE III -> protrusion manually reduced
GRADE IV -> protrusion that does not reduce
How are hemorrhoids treated?
- first & degree: conservative, inject sclerotherapy, rubber band ligation, photocoagulation
- third & fourth: surgery
if secondary piles -> treat the cause
If pile prolapse is circumferential, which surgical procedure is done?
stapled hemorrhoidectomy
What is the cause of perianal hematoma?
rupture of dilated anal vein as a result of severe straining
- sudden onset of painful lump inn the anus
- swelling tense & tender
- bluish in color with smooth shining skin
How is a perianal hematoma treated?
- if patient presents within 48hrs -> evacuation
- if patient presents late -> conservative treatment
- if untreated -> resolution
- > ulceration
- > suppuration
- > fibrosis gives rise to skin tag
What are the causes of ano-rectal suppurations?
- infected hair follicle, sebaceous cyst, perianal hematoma or fissure
- infection while treating piles
- spread of infection from nearby organs
- Crohn’s disease, cancer, leukemia, & lymphoma
What are the clinical features of ano-rectal suppuration?
- pain increasing with perianal movement
- pruritis
- generally unwell
- fever
- swelling
- cellulitis
- induration
- fluctuation
- subcutaneous mass
- DRE: fluctuation BUT DONT WAIT till u feel it
What are the classifications of anorectal abscesses?
- perianal 60%
- ischiorectal 20%
- intersphincteric 15%
- supralevator 4%
What investigations are used to diagnose anorectal abscesses?
anal ultrasonography
CT
MRI
How are anorectal abscesses treated?
early drainage because delay can cause
- prolonged infection
- tissue destruction
- chances of sphincter dysfunction
- promotes fistula formation
What are the causes of anal fistulas?
- Crohn’s
- ulcerative colitis
- cancer rectum
What are the classifications of anal fistulas?
- inter-sphincteric 70% -> internal sphincter to intersphincteric space then perineum
- trans-sphincteric 25% -> internal & external sphincter into ischiorectal fossa then perineum
- supra-sphincteric 4% -> intersphincteric space to above puborectalis muscle into ischiorectal fossa then peritoneum
- extra-sphincteric 1% -> from perianal skin through levator ani to rectal wall
What is Goodsall’s rule?
- any anterior fistula that is 3cm or less from the anus has a straight course
- any anterior fistula that is more than 3cm away from anus curves to the back
- any posterior fistula has a curved course
What are the imaging studies used to see a fistula?
1- fistulography -> may not be accurate due to fibrosis
2- MRI -> study of choice
How are fistulas treated?
- fistulotomy -> reroof the canal & curettage the floor -> heals by fibrosis
- fistulectomy -> complete excision of tract
- for high fistula: two stage operation SETON PLACEMENT
- anorectal fistula: conical drainage
What are the indications of Seton placement?
- complex fistula
- recurrent fistula
- anterior fistula in females
- poor pre-op sphincter pressure
- immunosuppressed
healing in 6 weeks
What is a pilonidal sinus?
- infective process occurring in natal cleft or sacrococcygeal region (between buttocks, umbilicus, & axilla)
- in young adults & teenagers
- common in hair dressers
What are the clinical features of pilonidal sinus?
- discharge
- throbbing pain
- swelling above coccyx in midline
- tufts of hair may be seen in opening
What are the complications of pilonidal sinus?
- sacral osteomyelitis
- necrotizing fasciitis
- meningitis
How are pilonidal sinuses treated?
in jackknife position (prone) all sinus tracts are removed + methylene blue is injected
- antibiotics with surgery
- incision & drainage if abscess
What are the causes of recurrence of a pilonidal sinus?
- improper removal
- existing diverticulum
- entry of new tufts of hair
- breakage of scar
