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Surgery block > Anal problems > Flashcards

Anal problems Flashcards

1
Q

Define haemorrhoids

A

Enlarged anal vascular cushions

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2
Q

What is the aetiology/risk factors for haemorrhoids?

A

Constipation and straining
Pregnancy
Obesity
Increased age
Increased intra-abdominal pressure (weight lifting or chronic coughing)

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3
Q

What are the anal cushions?

A

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

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4
Q

What are the different classifications of haemorrhoids?

A

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

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5
Q

What are the symptoms of haemorrhoids?

A

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

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6
Q

What are the signs of a haemorrhoid on examination?

A

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

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7
Q

What are the important differentials for rectal bleeding?

A

Anal fissures
Diverticulosis
Inflammatory bowel disease
Colorectal cancer

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8
Q

What treatment can be given for symptomatic relief from haemorrhoids?

A

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.

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9
Q

How to prevent and treat constipation in terms of haemorrhoids?

A

Increasing amount of fibre in the diet
Maintaining a good fluid intake
Using laxatives where required
Avoid straining when opening bowel

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10
Q

What is the non-surgical treatment for haemorrhoids?

A

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

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11
Q

What are the surgical treatment options for haemorrhoids?

A

Artery ligation
Harmoeehodectomy - caution removal of anal cushions can cause anal incontinence
Stapled haemorrhoidectomy

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12
Q

How do thrombosed haemorrhoids present?

A

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

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13
Q

What is a perianal abscess?

A

Infection (norm bacteria in anal glands) causing collection of pus near the anus.

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14
Q

How does a perianal absecess present?

A

Severe perianal pain
Swelling
Systemic symptoms - fever, malaise, fatigue
Erythema
Tenderness
Anorectal discharge
Dyschezia (unable to poo because of pain)
Anorectal mass - DRE

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15
Q

What are some risk factors for a perianal abscess?

A

Anal fissure
Constipation/diahorrea
IBD
DM
Immunsuppression
Underlying malignancy
30-40yrs
Male

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16
Q

What is the relevant pathophysiology underlying perianal abscess?

A

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.

17
Q

What is a anal fistulae?

A

Chronic abnormal communications between the epitheliased surface of the anal canal and the skin
Cause chronic discharge, pain and recurrent abscesses

18
Q

What are the different types of anal abscess by anatomy?

A

Intersphincteric - most common
Ischiorectal - spread down external shincter
Perianal - spread through skin into perianal space
Supralevator - infections spreads superiorly or originates in pelvis

19
Q

What investigations may be done for an anal abscess?

A

Digital rectal exam
Inspection of anus
Colonscopy, inflammatory markers and blood cultures - for underlying cause
MRI (gold standard)
Transperineal ultrasound

20
Q

What is the treatment for a perianal abscess?

A

Surgical - incision and drainage
Local anaesthetic
Wound packed or left open -> heal in 3to4 weeks
Antibiotics is systemic upset

21
Q

What are some complications of a perianal abscess?

A

Fistula-in-ano
Sepsis
Necrotising fasticits
Anorectal structure
Incontinence

22
Q

What is an anal fissure?

A

Longitudinal tear in the anoderm

23
Q

What are the risk factors for an anal fissure?

A

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

24
Q

What is the relevant pathophysiology of anal fissures?

A

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

25
Q

Where are most anal fissures found?

A

90% on the posterior midline

26
Q

What is the time span for a acute/chronic anal fissure?

A

6 weeks

27
Q

What are the clinical features of anal fissures?

A

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

28
Q

What is the management of an acute anal fissure?

A

High fibre diet and high fluid intake
Bulk forming laxatives - first line
Lubricatns before defecation
Topical anaesthetics
Analgesia

29
Q

What is the management of a chronic anal fissure?

A

As acute
GTN topical spray - 8w - then secondary care refally for surgery or botulinum toxin

30
Q

What is goodalls rule relating to anal fistulas?

A

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

Surgery block (24 decks)

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