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General Surgery > Anal disorders > Flashcards

Anal disorders Flashcards

1
Q

Define haemorrhoids

A

Abnormal vascular dilatation of anal mucosal cushions

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2
Q

How are haemorrhoids classified?

A

External or internal depending on origin in relation to the dentate line (transition between upper and lower anal canal).

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3
Q

Define external haemorrhoids (3)

A

Originate below dentate line
Covered by modified squamous epithelium (anoderm)
Richly innervated with pain fibres ➔ itchy and painful

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4
Q

Define internal haemorrhoids

A

Originate above dentate line
Covered by columnar epithelium
No pain fibres ➔ not sensitive to touch, temperature, or pain (unless strangulated)

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5
Q

What and where is the dentate line?

A

The transition between the upper and lower anal canal. Located 2cm from the anal verge.

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6
Q

Outline grading of internal haemorrhoids

A

I. project into lumen of anal canal but does not prolapse

II. prolapse on straining but reduce spontaneously when straining stops

III. prolapse on straining and requires manual reduction

IV. prolapsed and incarcerated and cannot be reduced

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7
Q

List 3 risk factors for haemorrhoids

A 
Constipation
Straining while trying to pass stools
Increasing age
Heavy lifting
Chronic cough
Pregnancy, childbirth
Obesity
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8
Q

Name 3 complications of haemorrhoids

A 
Ulceration
Skin tags
Maceration of perianal skin (softening and breakdown of skin)
Ischaemia
Thrombosis
Gangrene

Rare: perianal sepsis, anaemia

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9
Q

Describe the presentation of haemorrhoids

A

Bright red, painless rectal bleeding (not mixed with faeces)
Discomfort
Pruritus ani
Tenesmus

Pain if Grade IV internal haemorrhoid or thromboses external haemorrhoid

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10
Q

How are haemorrhoids investigated?

A

Proctoscopy

Sigmoidoscopy: used if sinister symptoms are present or elderly

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11
Q

Outline the non-pharmacological management of haemorrhoids

A

Healthy, high fibre diet
Increased fluid intake
Minimising straining
Good anal hygiene: aids healing, reduces irritation

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12
Q

Outline the pharmacological management of haemorrhoids

A

Simple analgesia e.g. paracetamol
Consider topical analgesia
-avoid NSAIDs if rectal bleeding present
Faecal softeners (decusate sodium and glycerol suppositories)
Laxative: osmotic movicol, or bulk fibrogel

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13
Q

Outline the secondary care management of haemorrhoids

A

Band ligation
Injection sclerotherapy

Haemorrhoidectomy
Haemorrhoidal artery ligation (HALO)

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14
Q

Define anal fissure

A

A tear or ulcer in the lining of the anal cannel, immediately within the anal margin

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15
Q

What is the commonest age group affected by anal fissures?

A

15-40yrs

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16
Q

Describe the presentation of anal fissure

A

Anal pain with defecation +/- bright red rectal bleeding

Anal spasm

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17
Q

Differentiate between acute and chronic anal fissures

A

Acute (<6wk) are superficial with well-demarcated edges

Chronic (6+wk) are wider and deeper with muscle fibres visible in the base. Edges often swollen, and skin tag may be visible.

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18
Q

Outline the non-pharmacological management of anal fissures

A

High fibre diet
Increased fluid intake
Avoid straining
Good anal hygiene

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19
Q

Outline the pharmacological management of chronic anal fissures

A

Analgesia
GTN 0.4% cream - if unhealed after 6-8wk with notable symptomatic improvement
Topical diltiazem 2% cream - if unhealed after 6-8wk, but no notable symptomatic improvement

Botox injection into internal sphincter

20
Q

Outline the surgical intervention for anal fissures

A

Lateral sphincterotomy - reduces internal sphincter spasms that impaired anal blood supply and reduced fissure healing

Avoid in females due to complications with childbirth and UTIs

21
Q

Describe the presentation of perianal abscess

A

Gradual onset, constant localised perianal pain
Associated swelling with tenderness +/- discharge
May have associated systemic features: fever, malaise, anorexia

22
Q

Name 2 organisms commonly implicated in perianal abscess

A

E. coli
Enterococcus spp.
Bacteroides spp.

23
Q

Name 3 risk factors of perianal abscess

A 
Crohn's disease
Diabetes mellitus
Anal fistula
Steroid use
Immunodeficiency
24
Q

Outline the management of perianal abscess

A

Surgical emergency

Incision and drainage

25
Q

Describe the pathophysiology of perianal abscess and subsequent fistula

A

Crypts of Morgagni that penetrate the internal sphincter become infected. This allows pus to tract to the anal margin and form an abscess.

If the abscess resolves, there is a fistula in this location connecting the anal cavity to the perianal skin.

26
Q

Outline the management of anal fistula

A

Seton stitch: A thread inserted through the fistula tract and tied outside in a loop. This allows the infection to drain and heal, without damaging the sphincter muscles.

Fistulotomy: Laying open of the fistula to allow healing by secondary intention.

27
Q

Define pilonidal sinus disease

A

Skin disorder featuring openings in the midline of the natal cleft, that allow loose hair and debris to enter creating an epithelial track (sinus)

28
Q

Name 3 risk factors for pilonidal sinus disease

A 
Male
15-40yr
Caucasian
Hirsutism
Obesity
29
Q

Describe the presentation of pilonidal sinus disease

A

Asymptomatic, or
Acute: pilonidal abscess
Chronically discharging sinus

30
Q

Name 2 complications of pilonidal sinus disease

A

Cellulitis
Sepsis
Chronic pain
Altered body image

31
Q

Outline the management of acute pilonidal abscess

A

Urgent incision and drainage
Analgesia
Advice to reduce recurrence: perianal hygiene, buttock hair removal techniques

32
Q

Outline the primary care management of discharging pilonidal sinus disease

A

Refer to colorectal or general surgical unit
Analgesia
Antibiotics if cellulitis suspected

33
Q

Outline the surgical management of discharging pilonidal sinus disease

A

For recurrent abscess or a small sinus ➔ pit picking method (removal of midline pit), excision of superficial abscess scars, drainage of track.

For chronic discharging sinuses ➔ wide excision of sinus tracks + primary closure or leaving wound open to heal by secondary intention. Cover with tissue flap if possible to minimise infection risk.

34
Q

What is the commonest type of anal cancer?

A

Squamous cell carcinoma (80%)

35
Q

Name 3 types of anal cancer

A

Squamous cell carcinoma (80%)
Melanoma
Lymphoma
Adenocarcinoma

36
Q

Outline the epidemiology of anal cancer

A

Uncommon (only 4% of lower GI cancers)
Incidence 1 in 10,000
F>M

37
Q

Which anal cancers are commoner in men?

A

Anal margin tumours: well differentiates, good prognosis

38
Q

Which anal cancers are commoner in women?

A

Anal canal tumours: poorly differentiated, worse prognosis

39
Q

Where do anal cancers most commonly metastasise?

A

Liver

Lungs

40
Q

Name 3 risk factors for anal cancer

A

Human papilloma virus (HPV): HPV risk increased by anal intercourse and high number of sexual partners
Men who have sex with men
HIV-positive

Immunosuppression in transplant recipients
Cigarette smoking
Previous malignancy

41
Q

Describe the presentation of anal cancer

A 
Rectal bleeding (50%)
Perianal pain
Palpable lesion
Faecal incontinence +/- mucus discharge
Perianal pruritus

20% asymptomatic

42
Q

How should anal cancer be investigated?

A

Rectal examination and biopsy
Staging: CT, MRI, endo-anal USS, PET
HIV serology
Metastases screening

43
Q

What system is used to stage anal cancer?

A

TNM staging

44
Q

Outline management of small well-differentiated carcinomas of the anal margin

A

Local excision

45
Q

Outline management of anal cancers that are larger, poorly-differentiated, or outside of the anal margin

A

Combined modality chemotherapy (5-fluorouracil + mitomycin C) and radiotherapy
Salvage surgery

46
Q

What are the surgical indications for anal cancer?

A

Tumours that fail to respond to radiotherapy
Large tumours causing GI obstruction
Small anal margin tumours without sphincter involvement

47
Q

Outline the pharmacological management of acute anal fissures

A

Bulk forming laxatives
Non-opioid analgesia
Topical anaesthetic

General Surgery (23 decks)

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