Anoreactal disorders Flashcards
________cause pain on defecation and usually
develop after a period of constipation (may be a
brief period) and tenesmus
Anal fissures
Usual location of anal fissure
On inspection the anal fissure is usually seen in
the anal margin, situated in the midline posteriorly
(6 o’clock)—90% of fissures
If there are multiple fissures, ______should
be suspected. These fissures look different, being
indurated, oedematous and bluish in colour
Crohn disease
In chronic anal fissures a sentinel pile is common
and in long-standing cases a _________ is
seen at the anal margin, with fibrosis and anal stenosis
subcutaneous fistula
Anal fissure
A combined_________ointment applied
to the fissure can provide relief and promote healing
local anaesthetic and corticosteroid
Purpose of hot sitz bath
Hot
baths relax the internal anal sphincter
________ is indicated in
patients with a recurrent fissure and a chronic fissure
with a degree of fibrosis and anal stenosis
Lateral internal sphincterotomy
An alternative
__________ which is as effective as
surgical treatment, is injection of botulinum toxin
into the sphincter
‘chemical’ sphincterotomy,
- Episodic fleeting rectal pain
- Varies from mild discomfort to severe spasm
- Last 3–30 minutes
- A functional bowel disorder
- Affects adults, usually professional males
Proctalgia fugax (levator ani spasm)
These ulcers occur in young adults; they can present
with pain but usually present as the sensation of
a rectal lump causing obstructed defecation and
bleeding with mucus.
Solitary rectal ulcer syndrome
Solitary rectal ulcer syndrome findings of sigmoidoscopy
The ulcer, which is usually seen
on sigmoidoscopy about 10 cm from the anal margin
on the anterior rectal wall, can resemble cancer.
_______ is an unpleasant sensation of incomplete
evacuation of the rectum. It causes the patient to
attempt defecation at frequent interval
Tenesmus
MC cause of tenesmus
The most
common cause is irritable bowel syndrome.
Other causes of tenesmus
Cancer, functional
A _________ is a purple tender swelling at the
anal margin caused by rupture of an external
haemorrhoidal vein following straining at toilet or
some other effort involving a Valsalva manoeuvre
perianal haematoma (thrombosed external haemorrhoid)
Tx of hematoma depends on?
the time of presentation after the
appearance of the haematoma
Mx of perianal hematoma
________Perform simple
aspiration without local anaesthetic using a 19
gauge needle while the haematoma is still fluid.
Within 24 hours of onset.
Mx of perianal hematoma
________The blood
has clotted and a simple incision under local
anaesthetic over the haematoma with deroofing
with scissors (like taking the top off a boiled
egg) to remove the thrombosis by squeezing
From 24 hours to 5 days of onset.
Mx of perianal hematoma
______ The haematoma is best left alone
unless it is very painful or (rarely) infected.
Resolution is evidenced by the appearance of
wrinkles in the previously stretched skin
Day 6 onwards.
A marked oedematous circumferential swelling will
appear if all the haemorrhoids are involved
Strangulated haemorrhoids
Strangulated haemorrhoids Tx
Initial treatment is with rest and ice packs and then
haemorrhoidectomy at the earliest possible time
This is caused by infection by polymicrobial organisms
of one of the anal glands that drain the anal canal
Perianal abscess
Tx of perianal abscess
Drain via a cruciate incision, which may need to be
deep (with trimming of the corners) over the point of
maximal induration. A drain tube can be inserted for
7 to 10 days.
Abx for perianal abscess
• metronidazole 400 mg (o) 12 hourly for 5–7 days
plus
• cephalexin 500 mg (o) 6 hourly for 5–7 days
An________ presents as a larger, more
diffuse, tender, dusky red swelling in the buttock.
The presence of an abscess is usually very obvious but
the precise focus is not always obvious on inspection
ischiorectal abscess
Recurrent abscesses and discharge in the sacral region
(at the upper end of the natal cleft about 6 cm from
the anus) caused by a ____ and ______
midline pilonidal sinus, which
often presents as a painful abscess
Pilonidal means ‘a
nest of hairs’ and the problem is particularly common
in ______
hirsute young men
An _____ is a tract that communicates between
the perianal skin (visible opening) and the anal canal,
usually at the level of the dentate line
anal fistula
Examples of Prolapsing lumps
Second- and third-degree haemorrhoids
Rectal prolapse
Rectal polyp
Hypertrophied anal papilla
Example of persistent lumps
Skin tag Perianal warts (condylomata accuminata) Anal cancer Fourth-degree haemorrhoids Perianal haematoma Perianal abscess
The______is usually the legacy of an untreated
perianal haematoma. It may require excision for
aesthetic reasons, for hygiene or because it is a source
of pruritus ani or irritation
skin tag
How to Tx skin tag
A simple elliptical excision at the base of the skin is
made under local anaesthetic. Suturing of the defect
is usually not necessary
It is important to distinguish the common viral warts
from the ______ of secondary syphilis
condylomata lata
Tx of warts
Local therapy includes the application of podophyllin
every 2 or 3 days by the practitioner or imiquimod
This is protrusion from the anus to a variable degree
of the rectal mucosa (partial) or the full thickness
of the rectal wall.
Rectal prolapse
Surgery such as ______ (fixing the
rectum to the sacrum) is the only effective treatment
for a complete prolapse.
rectopexy
_________ are a
complex of dilated arteries, branches of the superior
haemorrhoidal artery and veins of the internal
haemorrhoidal venous plexus
Internal haemorrhoids
Stages of Internal haemorrhoids
________
three bulges form above the dentate line. Bright
bleeding is common.
Stage 1: First-degree internal haemorrhoids:
Stages of Internal haemorrhoids
_____
the bulges increase in size and slide downwards
so that the patient is aware of lumps when
straining at stool, but they disappear upon
relaxing. Bleeding is a feature.
Stage 2: Second-degree internal haemorrhoids:
Stages of Internal haemorrhoids
______ the
pile continues to enlarge and slide downwards,
requiring manual replacement to alleviate
discomfort. Bleeding is also a featu
Stage 3: Third-degree internal haemorrhoids:
Stages of Internal haemorrhoids
________________
prolapse has occurred and replacement of the
prolapsed pile into the anal canal is impossible
Stage 4:
Fourth-degree internal haemorrhoids:
Invasive treatment of haemorrhoids is based on three main procedures: 1 2 3
rubber band ligation, cryotherapy and
sphincterotomy
Tx of hemorrhoid
Injection is now not so favoured while
a meta-analysis concluded that _____
was the most effective non-surgical therapy
rubber band ligation
________ refers to the involuntary escape
of fluid from or near the anus
Anal discharge
Types of continent anal discharge
• Anal fistula • Pilonidal sinus • STIs: anal warts, gonococcal ulcers, genital herpes • Solitary rectal ulcer syndrome • Cancer of anal margin
Types of incontinent anal discharge
- Minor incontinence—weakness of ____
- Severe incontinence—weakness of ___
internal sphincter
levator ani
and puborectalis
Partially continent anal discharge
- Faecal impaction
* Rectal prolapse
Mx of anal incontinence
1
2
3
4
direct sphincter repair,
directed injections such as collagen and
silicone into the anal sphincter, and an
artificial anal sphincter
A colostomy
may be the last resort
Black tarry (melaena) stool indicates bleeding from the upper gastrointestinal tract and is rare distal to the \_\_\_\_
lower ileum.
Frequent passage of blood and mucus indicates
a ________ whereas more proximal
tumours or extensive colitis present different patterns
rectal tumour or proctitis,
Substantial haemorrhage, which is rare, can be caused by 1 2 3 4
diverticular disorder,
angiodysplasia or
more proximal lesions such as Meckel diverticulum
and even duodenal ulcers
_______ are
5 mm collections of dilated mucosal capillaries and
thick-walled submucosal veins, found usually in the
ascending colon of elderly patients who have no
other bowel symptom
Angiodysplasias
DDx
Bright red blood on toilet paper
Internal haemorrhoids Fissure Anal cancer Pruritus Anal warts and condylomata
Blood and mucus on
underwear
Third-degree haemorrhoids Fourth-degree haemorrhoids Prolapsed rectum Mucosal prolapse Prolapsed mucosal polyp
Blood on underwear (no
mucus
Ulcerated perianal
haematoma
Anal cancer
Blood and mucus mixed
with faeces
Colorectal cancer Proctitis Colitis, ulcerative colitis Large mucosal polyp Ischaemic colitis
Blood mixed with faeces (no
mucus)
Small colorectal polyps
Small colorectal cancer
Melaena (black tarry stools
Gastrointestinal bleeding (usually upper) with long transit time to the anus
Torrential haemorrhage
Diverticular disorder
Angiodysplasia
Large volumes of mucus in
faeces (little blood
Villous papilloma of rectum
Villous papilloma of colon
What are the red flags in rectal bleeding
- Age >50 years
- Change of bowel habit
- Weight loss
- Weakness, fatigue
- Brisk bleeding
- Constipation
- Haemorrhoids (may be sinister)
- Family history of cancer
Causes of Pruritus ani
It is seen typically in adult males with considerable inner drive, often at times of stress and in hot weather when sweating is excessive.
Seborrhoeic dermatitis is a particularly common underlying
factor.
T or F
Most cases of uncomplicated pruritus ani resolve
with simple measures, including explanation and
reassurance
T
How to manage intractable pruritus ani
Otherwise prescribe a corticosteroid, especially
methylprednisolone aceponate 0.1%. Once
symptoms are controlled, use hydrocortisone 1
Consider _____ and ____ in patients presenting with ‘a sore
bottom
perianal lichen simplex and lichen
sclerosus
