Anal Disease Flashcards
What are haemorrhoids?
abnormal swelling or enlargement of the anal vascular cushions
What divides the anal canal?
pectinate line - divides into upper and lower
What lines the upper 2/3rds of the anal canal?
continues down from rectum
lined with same columnar epithelium
What lines the lower 1/3rd of the anal canal?
stratified squamous epithelium
Where in the anal canal has sensory innervation?
the lower 1/3rd - below the pectinate line
What are the degrees of haemorrhoid?
1st degree - remain in rectum
2nd degree - prolapse on straining but spontaneously reduce
3rd degree - prolapse on straining, require digital reduction
4th degree - permanently prolapsed
What are risk factors for haemorrhoids?
low fibre diet
increased intra abdo pressure - pregnancy, ascites
age
chronic constipation
What are the clinical features of haemorrhoids?
painless bright red PR bleeding, after defecation
not mixed with stool, on paper
pruritus
if thrombosed: very painful, tense lump, acute presentation
What are investigations for haemorrhoids?
usually clinical diagnosis exclude other anal disease and other causes of rectal bleeding history and examination FBC - anaemia? proctoscopy
What are management options for haemorrhoids?
conservative: laxatives, high fibre diet, topical analgesia
rubber band ligation (symptomatic 1st and 2nd degree)
haemorrhoidectomy (3rd/4th degree, unresponsive to conservative)
What is a pilonoidal sinus?
formation of a sinus in the cleft of the buttocks (cavity connected to surface of skin via sinus tract)
starts with obstructed hair follicle
What are the clinical features of a pilonoidal sinus?
fluctuating, red, painful mass
discharge
opens onto skin, but does not connect to anal canal (do sigmoidoscopy or MRI to assess for internal opening - fistula)
How are pilonoidal sinuses managed?
removal of sinus tract - excision
if abscess - incision and drainage
What is an anal fissure?
tear in mucosal lining of anal canal
caused by trauma e.g. hard stool
What are the classifications of anal fissures?
acute <6 weeks
chronic >6 weeks
What are clinical features of anal fissures?
intense pain during and after defecation - ‘pooing glass’
PR bleed - bright red
itching
on exam - visible fissure, can’t tolerate PR
How are fissures managed?
reduce risk factors, topical analgesia
stool softeners e.g. lactulose
GTN cream, diltiazem
surgery - botox injections, lateral spincterotomy (risk of faecal incontinence)
What is an anal fistula?
abnormal connection between anal canal and peri anal skin (2 epithelial structures)
What are the majority of anal fistulas associated with?
an abscess
What are clinical features of an anal fistula?
external opening seen on examination
discharge onto perineum
recurrent perianal abscesses
How are fistulas investigated?
proctoscopy - visualise the opening of tract into anal canal
MRI - if complex
investigations for Crohn’s
How are fistulas managed?
fistulotomy - superficial disease
Seton drain - high tract disease
How are suspected abscesses investigated?
EUA
if chronic or complex - MRI or CT
What are some clinical features of an anorectal abscess?
localised swelling and redness
progressive pain - perianal
rigors, fever, sepsis
itching, discharge
