Anal/Rectal Pathologies Flashcards
what are the cause of haemorrhoids?
- Constipation (result of straining)
* Others: pelvic tumour, pregnancy, CCF, portal hypertension
what are haemorrhoids?
Are disrupted and dilated anal cushions
what are the locations of anal cushions?
3, 7 and 11 o’clock
what are anal cushions?
o The anus is lined with mainly discontinuous masses of spongy vascular tissue – the anal cushions, which contribute to anal closure
what is the pathophysiology of piles?
The effects of gravity increased anal tone, and the effects of straining at stool may make anal cushions become bulky and loose, and so to protrude become more congested and hypertrophy to protrude again more readily.
what are the consequences of haemorrhoids?
vulnerable to trauma and bleeding
may strangulate
what are the types of haemorrhoids?
Internal
External
Mixed
what are the features of internal haemorrhoids?
o Painless and covered with music
o As they arise internally there are no pain receptors in this area = painless
o Origin above dentate line (internal rectal pleuxus)
what are the classification criteria for internal haemorrhoids?
1st Degree – remain in the rectum
2nd Degree – prolapse through the anus of defecation but spontaneously reduce
3rd Degree – as for 2nd degree but require digital reduction
4th Degree – remain persistently prolapsed
what are the features of external haemorrhoids?
o Painful
o Covered with skin
o Form at the anal opening
o Painful if develop thrombus
what are the features of mixed haemorrhoids?
o Origin above and below dentate line (internal and external plexus)
what are the clinical features of haemorrhoids?
- Bright red rectal bleeding
- Discomfort
- Mucus discharge
- Pruritus anal
- Anaemia and thrombosis are complications
- Pain on passing stool (external haemorrhoids)
how are haemorrhoids diagnosed?
- Abdominal examination
- PR exam
- Proctoscopy
- Sigmoidoscopy
what is the medical management of haemorrhoids?
o Increased fluid and fibre +/- topical analgesics and stool softener
o Topical steroids for short term – anusol, proctosedyl, 2% diltiazem cream
for what stages of haemorrhoids is medical management used?
1st degree
what is the non-operative management of haemorrhoids?
o Rubber band ligation
o Sclerosants
o Infra-red coagulation
o Cryotherapy
for what stages of haemorrhoids is non-operative management used?
2nd or 3rd degree, or failed 1st degree
what is the surgical management of haemorrhoids?
o Excisional haemorrhoidectomy
o Stapled haemorrhoidopexy
what are the causes of anal fissures?
- Primary problem in young to middle aged adults
* Crohn’s and UC
what is an anal fissure?
a tear in the skin that lines the anus below the level of the dentate line
where are anal fissures commonly found?
midline posteriorly
what is a sentinel pile?
An oedematous skin tag is common next to the lesion
what are the clinical features of anal fissures?
- Acute pain – stinging, occurs after passage
- Slight bleeding
- Patient is constipation
- On examination sphincter is in spasm – sentinel pule
what is the management of anal fissures?
- Heal spontaneously
- Anaesthetic cream and stool softener - Nitric oxide, 2% diltiazem cream
- Surgical
what are the causes of a fistula in ano?
- Crohn’s and ulcerative colitis
- Carcinoma
- Abscesses? Bacteria?
what is a fistula in ano?
Fistulas and sinuses in relation the anal canal
how is a fistula in ano formed?
Result from an initial abscess forming in one of the anal glands that pass from the submucosa of the anal canal to open within its lumen
what is the classification of fistulas in ano?
- Submucous
- Subcutaneous
- Inter-sphincteric
- Trans-sphincteric
- Supra-sphincteric
- Anorectal
- Superficial
- Low anal
- High anal fistulas –
what is the definition of a superficial fistula in ano?
subcutaneous or submucous and are superficial tracks resulting from rupture
what is the definition of a low anal fistula?
track is below the anorectal ring
what is the definition of a high anal fistula?
supra-sphincter fistulas pass via the inter-sphincter space to open into the anus above the puborectalis
what are the clinical features of fistulas in ano?
- Initial anorectal abscess which discharges
- Recurrent episodes of perianal infection = persistent discharge
- External opening of fistula
- Internal opening may be felt
- Squirt water in it will come out of anus
how are fistulas in diagnosed?
Endoanal ultrasound or MRI
how are superficial and low fistulas in ano managed?
laid open and allowed to heal by granulation
how are high fistulas managed?
injected with fibrin glue or a bioprosptehitc fistula plug
o If fails laid open and nylon is passed through and left in place for 2-3 weeks
anorectal abscesses are more common in which gender?
male
what are the causes of anorectal abscesses?
- Gay men – penetrative sex
* Crohn’s UC< TB
what is a perianal abscess?
resulting from infection of a hair follicle, sebaceous gland or a perianal haematoma
what is a submucous abscess?
infected fissure or laceration of the anal canal
what is a ischioanal abscess?
from infection of an anal gland leading from the anal canal into the submucosa, spread of infection from a perianal abscess, or penetration of the ischiorectal fossa by a foreign body. The abscess may form a track like a horse-shoe behind the rectum to the opposite ischiorectal fossa.
what is a pelvirectal abscess?
spread from pelvic abscess
what are the clinical features of an anorectal abscess?
Painful tender swellings and discharge
what is the surgical management of an anorectal abscess?
Surgically excised and drained, Antibiotics follow up
what are the causes of a rectal prolapse?
- Constipation and chronic straining
* Intussception
what are the two types of rectal prolapse?
Partial and Complete
what are the causes of partial rectal prolapses?
Infants: otherwise healthy
Adults: piles or sphincter incompetence
what is the presentation of partial anal prolapse in adults?
pruritis ani
what is the definition of a partial rectal prolapse?
confined to the mucosa, which prolapses 2-5cm from the anal verge. Palpation of the prolapse between the finger and thumb reveals that there is no muscular wall within it.
what are the clinical features of complete rectal prolapse?
incontinence
mucus discharge
what is the definition of complete rectal prolapse?
involves all layers of the rectal wall
who is commonly affected by complete rectal prolapse?
elderly women
what is the management of partial rectal prolapse?
excision of redundant mucosa, or a submucosal phenol-in-oil injection in order to produce sclerosis. Children, self cure
what are management options for rectal prolapse?
- Transabdominally – transabdominal mesh rectopexy
- Perineal – anal encirclement with a Thiersch wire
- Delorme’s Procedure
- Altemeier perineal rectosigmoidectomy
what are the complications of rectal prolapse?
- Intussusception
* Solitary Rectal Ulcer Syndrome
what are hyperplastic polyps?
these are small 2-3mm, sessile, wart-like lesions. Often multiple and virtually always benign, this is an incidental finding on sigmoidoscopy.
what are neoplastic polyps?
three histological types of benign neoplastic polyp, all of which may undergo malignant change. Multiple polyps are present in familial adenomatous polyposis
what are tubular adenomas?
usually small and rounded, the most common type of adenomatous polyp; the epithelium is arranged in tubular fashion
what are villous adenoma?
appears like an anemone with many frons growing from its base on the rectal wall. Often grows very large, and produces a large amount of mucus. Greatest potential for malignant change, so best completely removed
what are hamartomatous polyps?
developmental malformation which presents in children and adolescents and which looks like a cherry on a stalk. It is always benign, presents with bleeding and may prolapse during defaecation
what are inflammatory polyps?
associated with colitis; is not true polyp but is oedematous mucosa against a background of ulcerated, mucosadenuded bowel wall
how are rectal polyps diagnosed?
biopsy
how are rectal polyps managed?
excision
what are the causes of rectal carcinomas?
same as colon cancers
what is the most common kind of rectal carcinoma?
adenocarcinoma
what is a less common kind of rectal carcinoma and where can it occur?
squamous carcinoma at the anal verge
what are the macrosocpic features of rectal carcinomas?
papillieferous, ulcerating (most common), stenosing, mucinous
what is the local spread of rectal carcinomas?
Circumferentially around the lumen of the bowel
Invasion through the muscular coat
Penetration into adjacent organs, for example prostate, bladder, vagina, uterus, sacrum, sacral plexus, ureters and lateral pelvic wall
what is the lymphatic spread of rectal carcinoma?
to regional lymph nodes along the inferior mesenteric vessels. At a late stage, there is invasion of the iliac lymph nodes and of the groin lymph nodes (by retrograde spread) and involvement of the supraclavicular nodes via the thoracic duct
where does seeding of colonic and rectal carcinomas occur?
peritoneal cavity
what are the clinical features of rectal carcinomas?
o Constipation and/or diarrhoea o Bleeding o Mucus discharge rectal pain, tenesmus o Ascites, abdominal distension, hepatosplenomegaly o Supraclavicular nodes, groin, jaundice
what imaging is done to diagnose rectal carcinomas?
- Sigmoidoscopy
- Colonoscopy
- CT
- MRI
how are rectal carcinomas treated?
- Surgery
* Preoperative radiotherapy +/- chemotherapy
what are the causes of anal carcinomas?
- HPV
- Genital warts and cervical cancer
- Immunosuppression
what are the types of anal carcinomas?
commonly squamous celled
rarely adenocarcinoma, basal cell, melanoma
what are the clinical features of anal carcinomas?
- Inguinal lymphadenopathy
- Passage of mucus/blood
- Pain
- Lump at anal verge
- Faecal incontinence
how are anal carcinomas diagnosed?
- Biopsy?
- MRI or CT
- Transrectal ultrasound
how are low grade anal carcinomas managed?
observation, may revert to normal
how are high grade and small T1 squamous anal carcinomas managed?
local resection
how are large anal carcinomas managed?
radiotherapy and chemotherapy
