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Kofi: Surgery + Gastroenterology > Anal Disorders > Flashcards

Anal Disorders Flashcards

1
Q

What are the types of Anal Cancer and where do they arise?

A
  • 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
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2
Q

What is Anal Intraepithelial Neoplasia?

A
  • 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
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3
Q

What are risk factors of Anal Cancer?

A
  • HPV infection
  • HIV infection
  • Increasing Age
  • Smoking
  • Immunosuppressant medication
  • Crohn’s Disease
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4
Q

What are clinical features of Anal Cancer?

A
  • 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.
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5
Q

What is the examinations for Anal Cancer?

A
  • 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.
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6
Q

What is the Nodal drainage for the Anal Region?

A
  • 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
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7
Q

What are imaging for Anal Cancer?

A
  • 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
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8
Q

What are differentials for Anal Cancer?

A

Benign

  • Haemorrhoids
  • Anal Fissure
  • Fistula-in-ano
  • Anal Warts

Malignant

  • Low Rectal Cancer
  • Skin Cancer
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9
Q

What is the medical management of Anal Cancer?

A
  • 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
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10
Q

What is the surgical management of Anal Cancer?

A
  • Surgical excision reserved for management of advanced disease after failure of chemoradiotherapy or early T1NO carcinomas
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11
Q

What are complications of management of Anal Cancer?

A

Short-term complication (CRT)

  • Dermatitis
  • Diarrhoea
  • Proctitis
  • Cystitis
  • Leucopenia and thrombocytpena

Long term (CRT)

  • Fertility issues
  • Faecal incontinence
  • Vaginal drynes
  • Erectile dysfunction
  • Rectovaginal fistula
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12
Q

What is an Anal Fissure?

A

Tear in mucosal lining of the anal canal commonly due to trauma from defecation of hard stool

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13
Q

What are Risk Factors for an Anal Fissure?

A
  • Constipation
  • Dehydration
  • Inflammatory Bowel Disease
  • Chronic Diarrhoea
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14
Q

What are clinical features of Anal Fissures?

A
  • Intense pain post defecation
  • Pain out proportion to size of fissure
  • Bleeding or itching post defecation
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15
Q

What are examination findings for Anal Fissures?

A
  • Fissure visible and/or palpable on DRE.
  • Present in posterior midline in most cases (may need anaesthetics)
  • Protoscopy required for fissure within Anal Canal
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16
Q

What is the medical management of Anal Fissures?

A
  • 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
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17
Q

What is the surgical management of Anal Fissures?

A

Lateral Sphincterotomy

  • Reserved for chronic fissures.
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18
Q

What is an Anal Fistula?

A
  • Abnormal connection between anal canal and perineal skin.
  • Associated with anorectal abscess formation and males
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19
Q

What are risk factors for Anal Fistula?

A
  • Anal abscess
  • Anorectal cancers
  • Inflammatory Bowel Disease
  • Systemic Disease
  • History of Trauma to Anal region
  • Previous radiation therapy to anal region
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20
Q

What are clinical features of Anal Fistulas?

A
  • 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
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21
Q

What are examination findings for Anal Fistula?

A
  • External opening on perineum seen which can be fully open or covered in granulation tissue
  • Fibrous tract may be felt under skin on DRE
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22
Q

What are Tests for Anal Fistula?

A
  • 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
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23
Q

What are the 4 types of Anal Fistulae?

A
  • Inter-sphinteric fistula (most common)
  • Trans-sphinteric fistula
  • Supra-sphinteric fistula (least common)
  • Extra-sphinteric fistula
24
Q

What is the Surgical Management of Anal Fistulae?

A
  • Fistulotomy
    • Involves laying tract open and allowing it to heal by secondary intention
25
Q

What is an Anorectal Abscess?

A
  • Collection of pus in the anal or rectal region.
    • Commonly men
26
Q

What are clinical features of Anorectal Abscesses?

A
  • Pain in perianal region which exacerbated when sitting down
  • Localised swelling
  • Itching
  • Discharge
  • Severe abscess may have fever, rigors, general malaise or sepsis
27
Q

What are examination findings of Anorectal Abscesses?

A
  • Red and tender abscess (surrounding cellulitis)
  • Discharge of purulent or haemorrhagic fluid
  • Digital rectal examination often revealed fluctuant tender mass (need anaesthesia often)
28
Q

What are management options for Anorectal Abscesses?

A
  • 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
29
Q

What are haemorrhoids?

A
  • Abnormal swelling or enlargement of anal vascular cushions.
  • Act to assist anal sphincter in maintaining continence
30
Q

What are the classifications of Haemorrhoids?

A
  • 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
31
Q

What are risk factors for Haemorrhoids?

A
  • Idiopathic
  • Excessive straining
  • Increasing Age
  • Raised Intra-abdominal pressure
32
Q

What are the clinical features of Haemorrhoids?

A
  • Painless bright red bleeding commonly after defecation.
  • Blood seen on surface of stool and not mixed in.
  • Pruritis
  • Prolapse
  • Soiling
33
Q

When are haemorrhoids painful?

A

Thrombosed haemorrhoids

34
Q

What are the examination findings of Haemorrhoids?

A
  • Normal unless prolapsed haemorrhoids
  • Thrombosed prolapsed haemorrhoid will present as:
    • Purple/blue
    • Oedematous
    • Tense
    • Tender perineal mass
35
Q

What are tests performed to assess Haemorrhoids?

A
  • Protoscopy
  • Flexible sigmoidoscopy or colonoscopy
36
Q

How are haemorrhoids managed non-surgically?

A
  • 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
37
Q

What are surgical management options for Haemorrhoids?

A
  • 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
38
Q

What are complications in surgical management of Haemorrhoids?

A
  • Bleeding
  • Infection
  • Constipation
  • Stricture
  • Anal fissures or faecal incontinence
39
Q

What are complications of Haemorrhoids?

A
  • Ulceration due to thrombosis
  • Skin Tags
  • Ischaemia, thrombosis or gangrene in 4th degree internal haemorrhoids
  • Perianal sepsis
40
Q

What is Pilonoidal Sinus Disease and risk factors?

A

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
41
Q

What is the pathophysiology of Pilonoidal Sinus Disease?

A
  • 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
42
Q

What are clinical features of Pilonoidal Sinus Disease?

A
  • 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
43
Q

What is the non-surgical management of Pilonoidal Sinus Disease?

A

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
44
Q

What is the surgical management of Pilonoidal Sinus?

A
  • 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
45
Q

How is a pilonidal sinus tract removed?

A

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
46
Q

What are Rectal Prolapses?

A

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
47
Q

What are clinical features of Rectal Prolapses?

A
  • Rectal mucus discharge
  • Faecal sliding
  • Bright red blood on wiping or even visible ulceration
48
Q

What are examination findings for Rectal Prolapses?

A
  • 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
49
Q

What is the conservative management of Rectal Prolapses?

A

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.
50
Q

What is the surgical management of Rectal Prolapses?

A

Choice is between an abdominal procedure and perineal procedure

  • Perineal Approach
    • Delormes operation
    • Altmeirs operation (More effective procedure)
  • Abdominal Approach
    • Rectopexy
51
Q

What can causes Anorectal Abscesses?

A
  • 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
52
Q

Which organisms can cause Anorectal Abscesses?

A
  • E.coli
  • Bacteriodes
  • Enterococcus
53
Q

What is the conservative management of Haemorrhoids?

A
  • Increasing daily fibre and fluid intake to avoid constipation
  • Laxative if necessary
  • Topical analgesia for pain relief considered
54
Q

How do full thickness rectal prolapses happen?

A
  • 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.
55
Q

What are test for Anal cancer if suspecting immunosuppression?

A

HIV test considered if suspected immunosuppression

Kofi: Surgery + Gastroenterology (14 decks)

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