Anal problems Flashcards
Define haemorrhoids
Enlarged anal vascular cushions
What is the aetiology/risk factors for haemorrhoids?
Constipation and straining
Pregnancy
Obesity
Increased age
Increased intra-abdominal pressure (weight lifting or chronic coughing)
What are the anal cushions?
Specialised submucosal tissue
Connections between arteries and veins = very vascular = rectal arteries
Supported by sm and ct
Help control anal continence
Found at 3,7 and 11 oclock
What are the different classifications of haemorrhoids?
1st degree = no prolapse
2nd degree = prolapse when straining return on relaxin
3rd degree =prolapse on strain, do not return on relax, can be pushed back
4th degree = prolapsed permanently
What are the symptoms of haemorrhoids?
Can be asymptomatic (constipation and straining)
Bright red blood, not mixed with stool, seen on tissue after opening bowels
Sote/itchy anus
Feeling a lump around or inside the anus
What are the signs of a haemorrhoid on examination?
External (prolapsed) visible on inspection as swellings covered in mucosa
Internal - felt on PR (may not be)
May prolapse is asked to bear down during inspection
Protoscopy - hollow tube into anal canal to visualise the mucosa
What are the important differentials for rectal bleeding?
Anal fissures
Diverticulosis
Inflammatory bowel disease
Colorectal cancer
What treatment can be given for symptomatic relief from haemorrhoids?
Topical treatment = reduce swelling
Anusol - astringents to shrink
Anusol HC - also contains hydrocortisone for short term use
Germoloids cream - lidocaine containing - LA
Proctosedyl ointment - cinchocaine and hydrocortisone - short term only.
How to prevent and treat constipation in terms of haemorrhoids?
Increasing amount of fibre in the diet
Maintaining a good fluid intake
Using laxatives where required
Avoid straining when opening bowel
What is the non-surgical treatment for haemorrhoids?
Rubber band ligation (remove blood supply)
Injection sclerotherapy - phenoil oil cause sclerosis and atrophy
Infra-red coagulation (damage blood supply)
Bipolar diathermy - electrical current destroy it
What are the surgical treatment options for haemorrhoids?
Artery ligation
Harmoeehodectomy - caution removal of anal cushions can cause anal incontinence
Stapled haemorrhoidectomy
How do thrombosed haemorrhoids present?
Strangulation at haemorrhoid base causes thrombosis
Very painful
Purplish, very tender, swollen lumps
Unable to do PR due to pain
Admit is present within 72hrs - surgical treatment
Self resolve in several weeks
What is a perianal abscess?
Infection (norm bacteria in anal glands) causing collection of pus near the anus.
How does a perianal absecess present?
Severe perianal pain
Swelling
Systemic symptoms - fever, malaise, fatigue
Erythema
Tenderness
Anorectal discharge
Dyschezia (unable to poo because of pain)
Anorectal mass - DRE
What are some risk factors for a perianal abscess?
Anal fissure
Constipation/diahorrea
IBD
DM
Immunsuppression
Underlying malignancy
30-40yrs
Male
What is the relevant pathophysiology underlying perianal abscess?
Obstruction of the anal glands - intersphincteric space - due to local trauma/inflammation/infection
Secretions (mucus) accumulate forming an abcess
Bacteria in faecal matter infiltrate the obstructed gland cause infections - E.coli, bacteriodies, staphy. aureus
Immune response and inflammation -> pus accumulation inc pressure in abscess causing pain
If continues to expand may perforate into surrounding tissue causing a fistulae.
What is a anal fistulae?
Chronic abnormal communications between the epitheliased surface of the anal canal and the skin
Cause chronic discharge, pain and recurrent abscesses
What are the different types of anal abscess by anatomy?
Intersphincteric - most common
Ischiorectal - spread down external shincter
Perianal - spread through skin into perianal space
Supralevator - infections spreads superiorly or originates in pelvis
What investigations may be done for an anal abscess?
Digital rectal exam
Inspection of anus
Colonscopy, inflammatory markers and blood cultures - for underlying cause
MRI (gold standard)
Transperineal ultrasound
What is the treatment for a perianal abscess?
Surgical - incision and drainage
Local anaesthetic
Wound packed or left open -> heal in 3to4 weeks
Antibiotics is systemic upset
What are some complications of a perianal abscess?
Fistula-in-ano
Sepsis
Necrotising fasticits
Anorectal structure
Incontinence
What is an anal fissure?
Longitudinal tear in the anoderm
What are the risk factors for an anal fissure?
Increased anal resting pressure -> inc internal sphincter strenght limits blood flow to anoderm
Trauma
Constipation
30-40yrs
Idiopathic (primary)
Secondary to IBD, infections (STIs), malignancy, iatrogenic
What is the relevant pathophysiology of anal fissures?
Mechanical injuey - micro tears, exacerbated by repeated trauma or strain
Ischaemic factors - impaired healing
Inflammation impair healing and promote tissue breakdown
Chronic - fibrosis and hypertrophy of the anal papillary and sentinelt pile formation, granulation tissue - can worsen mechanical and ischaemic injury leading to non healing fissure
Where are most anal fissures found?
90% on the posterior midline
What is the time span for a acute/chronic anal fissure?
6 weeks
What are the clinical features of anal fissures?
Pain - sharp, severe, localised, worse during and after defecation (lasting from mins to hours)
Rectal bleeding - bright red
Pruritus ani
Discharge - mucopurulent
Constipation - due to avoidance of bowel movement
Exam - eryhtema, oedema, discharge, posterior midline, linear tear, sentinela tear at distal end
Gentle palpation - tenderness or induration
What is the management of an acute anal fissure?
High fibre diet and high fluid intake
Bulk forming laxatives - first line
Lubricatns before defecation
Topical anaesthetics
Analgesia
What is the management of a chronic anal fissure?
As acute
GTN topical spray - 8w - then secondary care refally for surgery or botulinum toxin
What is goodalls rule relating to anal fistulas?
Transverse line across anus
Superior to line and within 3cm of anus - internal opening will be radial to external opening of fistula
Inferior to line or more than 3cm away for external opening - internal opening will be in the posterior midline
