Anal Disease

Question 1

What are haemorrhoids?

Answer 1

abnormal swelling or enlargement of the anal vascular cushions

Question 2

What divides the anal canal?

Answer 2

pectinate line - divides into upper and lower

Question 3

What lines the upper 2/3rds of the anal canal?

Answer 3

continues down from rectum

lined with same columnar epithelium

Question 4

What lines the lower 1/3rd of the anal canal?

Answer 4

stratified squamous epithelium

Question 5

Where in the anal canal has sensory innervation?

Answer 5

the lower 1/3rd - below the pectinate line

Question 6

What are the degrees of haemorrhoid?

Answer 6

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

Question 7

What are risk factors for haemorrhoids?

Answer 7

low fibre diet
increased intra abdo pressure - pregnancy, ascites
age
chronic constipation

Question 8

What are the clinical features of haemorrhoids?

Answer 8

painless bright red PR bleeding, after defecation
not mixed with stool, on paper
pruritus

if thrombosed: very painful, tense lump, acute presentation

Question 9

What are investigations for haemorrhoids?

Answer 9

usually clinical diagnosis 
exclude other anal disease and other causes of rectal bleeding 
history and examination 
FBC - anaemia?
proctoscopy

Question 10

What are management options for haemorrhoids?

Answer 10

conservative: laxatives, high fibre diet, topical analgesia

rubber band ligation (symptomatic 1st and 2nd degree)

haemorrhoidectomy (3rd/4th degree, unresponsive to conservative)

Question 11

What is a pilonoidal sinus?

Answer 11

formation of a sinus in the cleft of the buttocks (cavity connected to surface of skin via sinus tract)
starts with obstructed hair follicle

Question 12

What are the clinical features of a pilonoidal sinus?

Answer 12

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)

Question 13

How are pilonoidal sinuses managed?

Answer 13

removal of sinus tract - excision

if abscess - incision and drainage

Question 14

What is an anal fissure?

Answer 14

tear in mucosal lining of anal canal

caused by trauma e.g. hard stool

Question 15

What are the classifications of anal fissures?

Answer 15

acute <6 weeks

chronic >6 weeks

Question 16

What are clinical features of anal fissures?

Answer 16

intense pain during and after defecation - ‘pooing glass’
PR bleed - bright red
itching
on exam - visible fissure, can’t tolerate PR

Question 17

How are fissures managed?

Answer 17

reduce risk factors, topical analgesia
stool softeners e.g. lactulose
GTN cream, diltiazem

surgery - botox injections, lateral spincterotomy (risk of faecal incontinence)

Question 18

What is an anal fistula?

Answer 18

abnormal connection between anal canal and peri anal skin (2 epithelial structures)

Question 19

What are the majority of anal fistulas associated with?

Answer 19

an abscess

Question 20

What are clinical features of an anal fistula?

Answer 20

external opening seen on examination
discharge onto perineum
recurrent perianal abscesses

Question 21

How are fistulas investigated?

Answer 21

proctoscopy - visualise the opening of tract into anal canal
MRI - if complex
investigations for Crohn’s

Question 22

How are fistulas managed?

Answer 22

fistulotomy - superficial disease

Seton drain - high tract disease

Question 23

How are suspected abscesses investigated?

Answer 23

EUA

if chronic or complex - MRI or CT

Question 24

What are some clinical features of an anorectal abscess?

Answer 24

localised swelling and redness
progressive pain - perianal
rigors, fever, sepsis
itching, discharge

Question 25

How are anorectal abscesses managed?

Answer 25

antiobiotic therapy
incision and drainage

proctoscopy - fistula? - Seton drain

Question 26

What are the majority of anal cancers?

Answer 26

squamous cell carcinomas

usually arising from below pectinate line

Question 27

What types of HPV are linked to anal cancer?

Answer 27

16 and 18

Question 28

What lymph nodes drain the anal canal below the pectinate line?

Answer 28

superficial inguinal

Question 29

What lymph nodes drain the anal canal above the pectinate line (and the rectal canal)?

Answer 29

internal iliac

Question 30

How might an anal cancer present?

Answer 30

rectal bleeding, pain
palpable and visible mass/lesions
discharge, pruritus

Question 31

How is anal cancer investigated?

Answer 31

EUA and biopsy
proctoscopy
staging: CT CAP (distant mets), MRI pelvis, USS guided FNA of nodes

Question 32

How are anal cancers managed?

Answer 32

chemoradiotherapy 
surgical excison (early tumours)