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Surgery > Anal Pain > Flashcards

Anal Pain Flashcards

1
Q

Acute Anal Fissures

Clinical

A

• Pain during defecation -> tearing pain
• Bleeding
− Streaks of blood on stool
− On toilet paper

• Persists for minutes to hours after defecation throbbing and aching pain

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2
Q

Acute Anal Fissures

Aetiology

A

Constipation: Forceful dilation of anal canal

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3
Q

Acute Anal Fissures

Pathogenesis

A

• Vicious cycle: tearing-pain-spasm

    1. Acute tear 
    2. Pain
    3. Causing an increase in sphincter tone -> which progresses to spasm -> ischaemia -> decreased healing potential
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4
Q

Acute Anal Fissures

Characteristics

A

12 (10% anterior midline) and 6 o’clock (90% posterior midline)

Fissure

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5
Q

Acute Anal Fissures

Differential

A
  • Chron’s disease
  • Anal Ca
  • TB (rarely)
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6
Q

Acute Anal Fissures

Management

A 
•	Conservative: WASH
       ⎫	W: warm water, shower or sitz bath after bowel movements
       ⎫	A: analgesia
       ⎫	S: stool softener
       ⎫	H: high fibre diet
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7
Q

Chronic Anal Fissures

Clinical

A

• Pain during defecation -> tearing pain
• Bleeding
− Streaks of blood on stool
− On toilet paper

• Persists for minutes to hours after defecation throbbing and aching pain

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8
Q

Chronic Anal Fissures

Aetiology

A

Constipation: Forceful dilation of anal canal

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9
Q

Chronic Anal Fissures

Pathogenesis

A

• Vicious cycle: tearing-pain-spasm

    1. Acute tear 
    2. Pain
    3. Causing an increase in sphincter tone -> which progresses to spasm -> ischaemia -> decreased healing potential
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10
Q

Chronic Anal Fissures

Characteristics

A

12 (10% anterior midline) and 6 o’clock (90% posterior midline)

  1. Fissure
  2. Inflammatory polyp inside
  3. Sentinal pile outside (inflammation fibrosis skin tag)
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11
Q

Chronic Anal Fissures

Differential

A
  • Chron’s disease
  • Anal Ca
  • TB (rarely)
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12
Q

Chronic Anal Fissures

Management

A

• Conservative: WASH
⎫ W: warm water/sitz baths after defecation
⎫ A: analgesia (topical e.g. remicane jelly INSIDE anus)
⎫ S: stool softener
⎫ H: high fibre diet

• Pharmacology
⎫ Topical CCB (nifedipine) 10mg/NO + remicane jelly
♣ Placed inside anus
♣ S/E: dizziness (hypotension)
⎫ Injected botulinum toxin (inhibits Ach relax the sphincter muscle increased blood flow + healing)

• Surgery (failed medical therapy; contraindication to medial therapy)
− Lot’s procedure (dilate sphincter)
− Lateral (TO ULCER) internal sphincterotomy (of involuntary i.e. internal muscle)
⎫ Disadvantage: 5% risk of fecal incontinence

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13
Q

Anorectal Abscess

Clinical

A
  • Severe, throbbing, anal pain + tenderness

* Worse with straining

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14
Q

Anorectal Abscess

Risk Factors

A

Host: immunosuppression
• DM
• Corticosteroids, chemotherapy
• Chron’s disease

Micro-organism

Contamination

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15
Q

Anorectal Abscess

Aetiology

A

• Trauma
− Abrasions (scratching)
− Penetrating

• Non-trauma
− Hair follicle
− Fissure
− Haemorrhoids

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16
Q

Anorectal Abscess

Aetiopathogenesis

A
  1. Crytoglandular theory
    − Infection cryptotitis OR trauma (from stool)
    − Oedema
    − Obstruction of drainage of anal gland (apocrine glands – scent)
    − Stasis
    − Bacterial overgrowth
    − Abscess of anal gland (in interspinteric space)
  2. Spread
    − Vertically downward (perianal)
    ⎫ Horizontally laterally (ischiorectal)
    − Vertically upward (supralevator)
    − Horizontally medially: submucosal, intramuscular
17
Q

Anorectal Abscess

Micro-organisms

A
  • E. coli
  • Proteus
  • Streptococci
  • Staphylococci
  • Bacteroides
  • Anaerobes
18
Q

Anorectal Abscess

A
  • Supralevator Abscess
  • Intramuscular Abscess
  • Submucosal Abscess
  • Perianal Abscess (60%)
  • Intersphincteric Abscess (5%)
  • Ischiorectal Abscess (20%)
19
Q

Anorectal Abscess

Complications

A

Fistula-in-ano

20
Q

Anorectal Abscess

Management

A 
Acutely
•	Analgesia
•	Antibiotics (if immune-compromised) 
•	Surgery 
        −	Drainage 
        −	If associated fistula  fistulotomy (reduce recurrence rate)

Post-op wounds/prevent recurrence
• Sitz baths/ water after defecation

21
Q

Fistula-In-Ano (Perianal Fistula)

Clinical

A
  • History of an abscess + drainage
  • Watery/purulent discharge + pruritus
  • Recurrent episodes of pain (if fistula fills with pus + bursts)
22
Q

Fistula-In-Ano (Perianal Fistula)

Aetiopathogenesis

A

• Abscess -> bursts in 2 directions:
− Anal canal
− Externally into the skin

23
Q

Fistula-In-Ano (Perianal Fistula)

Classification

A

(diagnose? Probe, hydrogen peroxide, MRI)

• Course: shape: internal opening
1. Goodsall’s rule
− If the external opening is anterior, the fistula usually runs directly into the anal canal
− If the external opening is posterior, the fistula usually curves to the posterior midline of the anal canal

• Course: fistulous tract
− Superficial
− Intersphincteric: The tract begins in the space between the internal and external sphincter muscles and opens very close to the anal opening
− Transspincteric: It then crosses the external sphincter and opens an inch or two outside the anal opening
− Extraspincteric: The tract begins in the space between the internal and external sphincter muscles and turns upward to a point above the puborectal muscle, crosses this muscle, then extends downward between the puborectal and levator ani muscle and opens an inch or two outside the anus

     −	Supraspincteric: The tract begins at the rectum or sigmoid colon and extends downward, passes through the levator ani muscle and opens around the anus
24
Q

Fistula-In-Ano (Perianal Fistula)

Management

A

Definitive
Conservative -> fibrin glue
Surgery
• Fistulotomy
− Does not involve external sphincter
1. Primary fistulotomy: unroof tract from external to internal opening, allow drainage, heals by secondary intention
− Involved external sphincter
1. Staged fistulotomy : skin and fat are divided but the muscles are left intact
2. Seton suture: a circular drain called a seton is placed from the external opening, through the tract and internal opening and brought out of the anal canal. It is then tied to itself as a loop
− Why?: risk of incontinence high if muscle cut as it is already compromised
− MOI: allows abscess to drain and to contract down. It also keeps the tract and external site open so that a new abscess is much less likely to develop
• Fistulectomy: excision of tract
− Disadvantage: associated with 3 x higher risk of flatulence + incontinence, therefore not first line

Post-op wound/reduce risk of recurrence
• Hygiene
− Sitz baths (OR just water if you can’t – for a couple of minutes)
⎫ After defecation
⎫ Water + salt, savlon, chlorhexidine
⎫ 30 mins
− Gauze after wash

Surgery (5 decks)

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