Anal + Perianal Disease Flashcards
what are haemorrhoids
abnormal swelling/enlargement of anal vascular cushions
what is the function of the anal vascular cushions?
how many are there?
they assist the anal sphincter in maintaining continence
- 3
how are heamorrhoids classified
according to size:
1st Degree: remain in rectum
2nd Degree: prolapse through anus on defecation but spontaneously reduce
3rd Degree: prolapse through anus on defecation and require digital reduction
4th Degree: remain persistently prolapsed
risk factors for haemorrhoids
excessive straining (from chronic constipation) increasing age raised intra-abdominal pressure (e.g. pregnancy, chronic cough, ascites)
presentation of haemorrhoids
painless bright red PR bleeding
- post defecation
- on surface of stool, not mixed in
itch, rectal fullness, soiling due to impaired continence
presentation of a thrombosed prolapsed haemorrhoid
purple/blue, oedematous, tense, tender perianal mass
what investigation confirms haemorrhoids
proctoscopy
management of haemorrhoids
lifestyle advice: increase daily fibre + fluid intake to avoid constipation
laxatives + topical lignocaine for symptom relief
symptomatic 1st/2nd degree haemorrhoids can be treated with rubber band ligation
3rd/4th degree haemorrhoids may require haemorrhoidectomy
what is pilondial sinus disease
formation of a sinus in the inter-gluteal cleft
- due to inflammation + obstruction of hair follicle – pit + cavity formation
who gets pilondial sinus disease
caucasian males with course dark body hair
most commonly 16-30 years old
increased risk in those who sit for prolonged periods e.g. lorry drivers / office workers
presentation of pilondial sinus disease
intermittent, red painful, swollen mass in sacrococcygeal region
- commonly purulent discharge
non-surgical management of pilondial sinus disease
shaving of the affected region
plucking the sinus free of hair that is embedded
surgical management of pilondial sinus disease
abscesses: incision + drainage and washout is required
chronic disease: removal of sinus tract
what is a perianal fistula
abnormal connection between anal canal + perianal skin
what are the majority of perianal fistulas caused by
a perianal abscess
risk factors for a perianal fistula
IBD - Crohns or UC
Systemic disease - TB, HIV, Diabetes
Trauma to anal region
presentation of perianal fistula
either:
- recurrent abscesses
- discharge onto perineum
imaging used to visulise a perianal fistula
proctoscopy
- MRI used in complex fistulas
what system is used to classify perianal fistulas
Park’s classification system
most common type of perianal fistula
inter-sphincteric fistula
surgical options for perianal fistulas
- fistulotomy
- placement of a seton to bring together + close the tract
what is an anorectal abscess
collection of pus in the anal-rectal region
what causes formation of an anorectal abscess
plugging of anal ducts resulting in fluid stasis + infection
infective organisms in an anorectal abscess
E.Coli
Enterococcus
presentation of an anorectal abscess
pain in the perianal region which is exacerbated by sitting down
what is found on examination of an anorectal abscess
an erythematous, fluctuant, tender perianal mass
management of an anorectal abscess
antibiotics + analgesia
surgical incision + drainage under GA
proctoscopy post drainage to look for any perianal fistulae
what is an anal fissure
tear in the mucosal lining of the anal canal
- most commonly due to trauma from defecation of a hard stool
how long does an anal fissure need to be present to be classified as
- acute
- chronic
acute = < 6 weeks chronic = > 6 weeks
presentation of an anal fissure
intense pain post defecation
PR bleeding - bright red on wiping
itch post defecation
where are most anal fissures located
posterior midline
medical management of an anal fissure
increase fibre + fluid intake
stool softening laxatives
topical lidocaine
GTN/Diltiazem cream – increases blood flow + relaxes anal sphincter, decreases pain + promotes healing
surgical management of an anal fissure
reserved for chronic fissure where medial management has failed to resolve symptoms:
- botox injections
- lateral sphincterectomy
difference between a
- partial thickness rectal prolapse
- full thickness rectal prolapse
partial thickness - rectal mucosa protrudes out of anus
full thickness - rectal wall protrudes out of anus
risk factors for rectal prolapse
increasing age female multiple deliveries straining anorexia
presentation of a rectal prolapse
rectal mucus discharge
faecal incontinence
PR bleeding
- full thickness prolapses begin internally and may present with rectal fullness + tenesmus
investigation of a rectal prolapse
PR - weakened anal sphincter
Ask patient to strain
definitive management of rectal prolapse
surgical repair
what are the majority of anal cancers
squamous cell carcinomas arising below the dentate line
anal cancer risk factors
HPV infection (HPV 16,18) HIV Smoking Crohns disease Immunosuppression
symptoms of anal cancer
rectal pain PR bleeding anal discharge itch palpable mass
investigation of anal cancer
PR
proctoscopy
examination under anaesthetic (EUA)
management of anal cancer
chemo-radiotherapy
abdominoperineal resection for advanced disease
