Anal Disorders Flashcards
What are the types of Anal Cancer and where do they arise?
- Squamous cell carcinoma (majority)
- arise from below the pectinate line
- Adenocarcinomas
- arise from the upper anal canal epithelium and the crypt glands.
- Melanomas
- Anal skin cancer
What is Anal Intraepithelial Neoplasia?
- May precede development of invasive squamous anal carcinoma
- High-grade AIN (grade 2 or 3) is premalignant and may progress to invasive cancer
- Can affect either perianal skin or anal canal.
- AIN strongly linked to infection with HPV
What are risk factors of Anal Cancer?
- HPV infection
- HIV infection
- Increasing Age
- Smoking
- Immunosuppressant medication
- Crohn’s Disease
What are clinical features of Anal Cancer?
- Pain and rectal bleeding (50% of patients)
- Anal discharge
- Pruritus
- Palpable Mass
- Perianal infection and fistula-in-ano
- Faecal incontinence and tenesmus
- anal sphincters invaded.
What is the examinations for Anal Cancer?
- Perineum and perianal region should be screened for any ulceration or presence of wart-like lesions.
- Assess presence of additional vulval or vaginal lesions
- DRE should be attempted. If mass palpable, document distance from anal verge where it is felt and fraction of the anal circumference which it occupies.
- Inguinal lymph nodes examined for lymphadenopathy.
What is the Nodal drainage for the Anal Region?
- Lymph nodes from below dentate line drain to superficial inguinal nodes
- Nodes in anal canal and rectum above the dentate line drain into mesorectal, para-aortic and paravertebral nodes
What are imaging for Anal Cancer?
- Protoscopy
- Done under anaesthetic
- Biopsy can be taken for histological confirmation.
- USS guided Fine Needle Aspiration for any palpable inguinal lymph nodes
- CT thorax-abdomen-pelvis for distant metastases
- MRI pelvis to assess extent of local invasion
What are differentials for Anal Cancer?
Benign
- Haemorrhoids
- Anal Fissure
- Fistula-in-ano
- Anal Warts
Malignant
- Low Rectal Cancer
- Skin Cancer
What is the medical management of Anal Cancer?
- Chemo-radiotherapy is first choice of treatment for most anal tumours.
- External beam radiotherapy to anal canal and inguinal lymph nodes combined with dual chemotherapy agents such as mitomycin C and 5-fluorouracil
What is the surgical management of Anal Cancer?
- Surgical excision reserved for management of advanced disease after failure of chemoradiotherapy or early T1NO carcinomas
What are complications of management of Anal Cancer?
Short-term complication (CRT)
- Dermatitis
- Diarrhoea
- Proctitis
- Cystitis
- Leucopenia and thrombocytpena
Long term (CRT)
- Fertility issues
- Faecal incontinence
- Vaginal drynes
- Erectile dysfunction
- Rectovaginal fistula
What is an Anal Fissure?
Tear in mucosal lining of the anal canal commonly due to trauma from defecation of hard stool
What are Risk Factors for an Anal Fissure?
- Constipation
- Dehydration
- Inflammatory Bowel Disease
- Chronic Diarrhoea
What are clinical features of Anal Fissures?
- Intense pain post defecation
- Pain out proportion to size of fissure
- Bleeding or itching post defecation
What are examination findings for Anal Fissures?
- Fissure visible and/or palpable on DRE.
- Present in posterior midline in most cases (may need anaesthetics)
- Protoscopy required for fissure within Anal Canal
What is the medical management of Anal Fissures?
-
Conservative
- Reducing risk factors and providing adequate analgesia
- Increasing fibre in the diet and fluid intake will help.
-
Medical
- 1st Line: Stool softening laxatives
-
2nd Line: GTN cream or Diltiazem cream.
- Increases blood supply to the region and relaxes internal anal sphincter, putting less pressure on the fissure promoting healing and reducing pain
What is the surgical management of Anal Fissures?
Lateral Sphincterotomy
- Reserved for chronic fissures.
What is an Anal Fistula?
- Abnormal connection between anal canal and perineal skin.
- Associated with anorectal abscess formation and males
What are risk factors for Anal Fistula?
- Anal abscess
- Anorectal cancers
- Inflammatory Bowel Disease
- Systemic Disease
- History of Trauma to Anal region
- Previous radiation therapy to anal region
What are clinical features of Anal Fistulas?
- Intermittent or continuous discharge onto perineum which can be mucus, blood, pus or faeces
- Severe pain
- Swelling
- Change in bowel habit
- Systemic features of infection
What are examination findings for Anal Fistula?
- External opening on perineum seen which can be fully open or covered in granulation tissue
- Fibrous tract may be felt under skin on DRE
What are Tests for Anal Fistula?
- Rigid sigmoidoscopy can be used to visualise opening of the tract in anal canal
- Further investigations such as fistulography, endo-anal ultrasound or MRI imaging for remaining tract
What are the 4 types of Anal Fistulae?
- Inter-sphinteric fistula (most common)
- Trans-sphinteric fistula
- Supra-sphinteric fistula (least common)
- Extra-sphinteric fistula
What is the Surgical Management of Anal Fistulae?
-
Fistulotomy
- Involves laying tract open and allowing it to heal by secondary intention
What is an Anorectal Abscess?
- Collection of pus in the anal or rectal region.
- Commonly men
What are clinical features of Anorectal Abscesses?
- Pain in perianal region which exacerbated when sitting down
- Localised swelling
- Itching
- Discharge
- Severe abscess may have fever, rigors, general malaise or sepsis
What are examination findings of Anorectal Abscesses?
- Red and tender abscess (surrounding cellulitis)
- Discharge of purulent or haemorrhagic fluid
- Digital rectal examination often revealed fluctuant tender mass (need anaesthesia often)
What are management options for Anorectal Abscesses?
- Requires some imaging typically MRI scan
-
Antibiotics
- Utilised for acute infective states especially in diabetes or immunocompromised patient.
-
Surgical drainage
- Typically performed under general anaesthetic.
- Prevent tissue damage including anal sphincter dysfunction.
- Allow to heal by secondary intention
What are haemorrhoids?
- Abnormal swelling or enlargement of anal vascular cushions.
- Act to assist anal sphincter in maintaining continence
What are the classifications of Haemorrhoids?
- 1st Degree: Remain in Rectum
- 2nd Degree: Prolapse through the anus on defacation but spontaneously reduce
- 3rd Degree: Prolapse through anus on defecation but requires digital reduction
- 4th Degree: Remain persistently prolapsed
What are risk factors for Haemorrhoids?
- Idiopathic
- Excessive straining
- Increasing Age
- Raised Intra-abdominal pressure
What are the clinical features of Haemorrhoids?
- Painless bright red bleeding commonly after defecation.
- Blood seen on surface of stool and not mixed in.
- Pruritis
- Prolapse
- Soiling
When are haemorrhoids painful?
Thrombosed haemorrhoids
What are the examination findings of Haemorrhoids?
- Normal unless prolapsed haemorrhoids
- Thrombosed prolapsed haemorrhoid will present as:
- Purple/blue
- Oedematous
- Tense
- Tender perineal mass
What are tests performed to assess Haemorrhoids?
- Protoscopy
- Flexible sigmoidoscopy or colonoscopy
How are haemorrhoids managed non-surgically?
-
Rubber-band Ligation
- Treat 1st degree and 2nd degree haemorrhoids.
- Haemorrhoids drawn into end of suction gun and rubber band placed over neck of the haemorrhoid
- Infrared coagulation/photocoagulation, bipolar diathermy or direct current electrotherapy.
- Haemorrhoidal artery ligation
What are surgical management options for Haemorrhoids?
- Haemorrhoidectomy (5%)
- Indicated if symptomatic and not responding to conservative therapies yet unsuitable for banding/injection.
- Typically this is either stapled haemorrhoidectomy or Milligan Morgan haemorrhoidectomy
- Painful procedure
What are complications in surgical management of Haemorrhoids?
- Bleeding
- Infection
- Constipation
- Stricture
- Anal fissures or faecal incontinence
What are complications of Haemorrhoids?
- Ulceration due to thrombosis
- Skin Tags
- Ischaemia, thrombosis or gangrene in 4th degree internal haemorrhoids
- Perianal sepsis
What is Pilonoidal Sinus Disease and risk factors?
Formation of a sinus in the cleft of the buttocks.
RISK FACTORS:
- Caucasian males with coarse, dark body hair
- People that sit for long periods of time
- Increased sweating
- Buttock friction
- Obesity
- Poor hygiene
- Local Trauma
What is the pathophysiology of Pilonoidal Sinus Disease?
- Hair follicle in the intergluteal cleft become infected or inflamed.
- Inflammation obstructs the opening of the follicle which extends inwards forming a pit
- Foreign body-type reaction may then lead to formation of a cavity connected to the surface of the skin by epithelised sinus tract
What are clinical features of Pilonoidal Sinus Disease?
- Intermittent red, panful and swollen mass in sacrococcygeal regions.
- Discharge from sinus and can have systemic features
- Extensive sinus formation and fistulisation may be assessed by MRI scanning of natal cleft and buttocks, but further imaging rarely necessary
What is the non-surgical management of Pilonoidal Sinus Disease?
Conservative management
- shaving the affected region and plucking the sinus free of any hair embedded.
- Any accessible sinuses can be washed out
- Antibiotic can be used in septic episodes although abscess require surgical drainage
What is the surgical management of Pilonoidal Sinus?
- Acute
- Surgical management involves drainage and wash of any abscess that is present.
- Difficult to remove sinus tract in same operation and most patient require further surgery
- Chronic disease
- Removal of pilonidal sinus tract
How is a pilonidal sinus tract removed?
1st line
- Involves excising tract and laying open the wound allowing closure by secondary intention.
- low rates of recurrence yet can take long time to heal and has an increased risk of infection
2nd line
- Involves excising the tract followed by primary closure of the wound.
- Higher rates of recurrence and patient may require reconstructive surgery due to tissue loss form operation
What are Rectal Prolapses?
Mainly affects women greater than 30 years of age.
- Types
- Partial thickness
- Rectal mucosa protrudes out of the anus
- Associated with loosening and stretching of the connective tissue that attaches the rectal mucosa to remainder of rectal wall.
- Often occurs in conjunction with long standing haemorrhoidal disease
- Full prolapse
- Rectal wall protrudes out of the anus
- Form of sliding hernia through a defect of the fascia of the pelvic regions.
- Caused by chronic straining secondary to constipation, a chronic cough or multiple vagina deliveries
- Partial thickness
What are clinical features of Rectal Prolapses?
- Rectal mucus discharge
- Faecal sliding
- Bright red blood on wiping or even visible ulceration
What are examination findings for Rectal Prolapses?
- Can be identified with or without strain.
- DRE is required, and weakened sphincter is often identified.
- Defecating proctography and examination under anaesthesia used for suspected internal prolapses
What is the conservative management of Rectal Prolapses?
Used for those unfit for surgery with minimal symptoms or in children
- Initial management include
- Improved dietary fibre and fluid intake
- Reducing constipation
- Time spent straining.
- Minor mucosal prolapses may be banded in clinic but this is prone to recurrence.
What is the surgical management of Rectal Prolapses?
Choice is between an abdominal procedure and perineal procedure
- Perineal Approach
- Delormes operation
- Altmeirs operation (More effective procedure)
- Abdominal Approach
- Rectopexy
What can causes Anorectal Abscesses?
- Caused by plugging of the anal ducts found in wall of anal canal which drain the anal glands.
- Anal glands secrete mucus into the anal canal to ease passage of faecal matter.
- Blockage of anal ducts causes stasis and allow normal bacterial flora to overgrow leading to infection
Which organisms can cause Anorectal Abscesses?
- E.coli
- Bacteriodes
- Enterococcus
What is the conservative management of Haemorrhoids?
- Increasing daily fibre and fluid intake to avoid constipation
- Laxative if necessary
- Topical analgesia for pain relief considered
How do full thickness rectal prolapses happen?
- Full thickness prolapses begin internally.
- Presents with sensation of rectal fullness, tenesmus or repeated defecation
- Rectum begins to prolapse with defecation then later with coughing and straining. Eventually comes completely external.
- Prolapses particularly prone to ulceration.
What are test for Anal cancer if suspecting immunosuppression?
HIV test considered if suspected immunosuppression
