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Yr3 Surgery: General > Anorectal > Flashcards

Anorectal Flashcards

1
Q

Define haematochezia

A

Passage of fresh blood from rectum

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2
Q

State some potential causes of haematochezia

A
  • Diveritcular disease or diverticulitis
  • Infective colitis
  • Hameorrhoids
  • IBD
  • Malignancy
  • Angiodysplasia
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3
Q

What scoring system can be used to risk stratify pts presenting with lower GI bleed to see if can be managed as outpatient?

A

Oakland

*Looks at age, sex, PR fidings, HR, systolic BP, hb

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4
Q

What investigations should you do for someone with haematochezia?

A

Bedside

  • Stool culture: rule out infection
  • DRE
  • Proctoscopy

Bloods

  • FBC
  • U&Es
  • LFTs
  • Clotting
  • Group & save or crossmatch

Imaging

  • Flexible sigmoidoscopy
  • OGD
  • Capusule endoscopy
  • CT angiogram
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5
Q

Remind yourself of anatomy of anal sphincter complex

A

Anal sphincter complex has internal and external part:

Internal sphincter

  • Involuntary- smoth muscle
  • 80% resting anal pressure
  • Autonomic control

External sphincter

  • Voluntary- striated muscle
  • 20% resting anal pressure
  • Pudendal nerve
  • Three sections:
    • Deep
    • Superficial
    • Subcutaneous
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6
Q

Remind yourself what the dentate line is

A

Junction of hindgut and proctodaeum (ectoderm)

Above dentate line:

  • Columnar epithelium
  • Visceral pain receptors

Below dentate line

  • Stratified squamous
  • Somatic pain receptors
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7
Q

What are the anal cushions

A
  • Three cusions of loose connective tissue arranged circumferentially around the dentate line.
  • Positioned at 3-, 7- and 11- O’clock
  • Contain haemorrhoidal (venous) plexus
  • Venous plexus can dilate to help with continence
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8
Q

What are haemorrhoids?

State two different types

A
  • Haemorrhoids= abnormal swelling or enlargment of anal vascular cushions
  • Haemorrhoids can be:
    • Internal: above dentate line
    • External: below dentate line
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9
Q

State some risk factors for haemorrhoids

A
  • Excessive straining from chronic constipation
  • Increasing age
  • Raised intra-abdominal pressure e.g.
    • Pregnancy
    • Chronic cough
    • Ascites

Less common= pelvic or abdo mass, cardiac failure, portal hypertension

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10
Q

Discuss the classification of haemorrhoids (what are the 4 different degrees of haemorrhoids)

A
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11
Q

State the clinical features of haemorrhoids

A
  • Painless haematochezia (typically on toilet tissue or after opening bowels. Blood NOT mixed with stool)
  • Pruritis
  • Anal lump
  • Rectal fullness
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12
Q

What investigations should you do if you suspect haemohorroids?

A

Bedside

  • Proctoscopy

Bloods

  • FBC: ?anaemia
  • Coagulation

Imaging

  • May do further investigations if quering other cause of rectal bleeding
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13
Q

Discuss the management of haemorrhoids, consider:

  • Conservative/lifestyle
  • Medical
  • Non-surgical
  • Surgical
A

Nearly all managed conservatively:

Conservative/lifestyle

  • Increase fibre
  • Adequete fliud intake
  • Avoid straining

Medical:

  • Laxatives if necessary
  • Anusol cream(contains chemicals to shrink haemorrhoids “astringents”)
  • Germoloids ointment (contains lidocaine and zinc oxide- zinc oxide can reduce size)
  • Anusol HC (contains hydrocortisone so only use short time)

Non-surgical

  • Rubber band ligation
  • Injection slcerotherapy (inject phenol oil to cause sclerosis & atrophy)
  • Infra-red coagulation (infra-red light applied to damange arteries)
  • Bipolar diathermy (use electrical current)

Surgical

  • Haemorrhoid artery ligation (suture vessels that supply haemorrhoid to cut off blood supply)
  • Haemorrhoidectomy (excising haemorrhoid)
  • Staple haemorrhoidectomy (use device that excises ring of haemorrhoid tissue at same time as adding a circle of staples ot anal canal. Staples stay in place long term)
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14
Q

State some potential complications of haemorrhoidectomy

A
  • Bleeding
  • Infection
  • Stricture
  • Anal fissures
  • Faecal incontinence
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15
Q

State some potential complications of haemorrhoids

A
  • Thrombosis
    • Ulceration or gangrene secondary to throbosis
  • Skin tags
  • Perianal sepsis
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16
Q

For thrombosed haemorrhoids, discuss:

  • Why they occur/pathophysiology
  • Presentation
  • Whether they resolve spontaneously & management
A

Strangulation at base of haemorrhoid leading to thrombosis in the haemorrhoid

  • Presentation:
    • Painful (very)
    • Tender (very)
    • Purplish/blue lump around anus
    • PR exam unlikely to be possible due to pain
  • Will resolve with time but it can take couple of weeks. NICE suggest considering referral for surgery (excision) if present within 72hrs and pt has extremely painful thrombosed haemorrhoids. If not for referral, manage with stool softners, analgesia & ice packs. Symptoms often settle in 10 days.
17
Q

What is a pilonidal sinus?

What age group most common in?

State some risk factors

A
  • Formation of sinus in the cleft of the buttocks
  • Younger age group (16-30yrs)
  • Risk factors:
    • Dark coarse body hair
    • Caucasian
    • Sit for prolonged periods of time
    • Obesity
    • Increased sweating
    • Local trauma
    • Poor hygiene
18
Q

Discuss the pathophysiology of pilonidal sinuses

A
  • Hair follicle in intergluteal cleft becomes inflamed or infected
  • Inflammation obstructs the opening of the follicle
  • Inflammtion obstructs the opening of the hair follicle
  • Hair follicle begins to extend inwards forming a pit and hair is trapped in pit
  • Foreign body type reaction then occurs leading to formation of a cavity= pilonidal cyst
  • Pilonidal cyst connects with skin via sinus tract
19
Q

Describe clinical features of a pilonidal sinus

A pilonidal sinus can become infected and form an abscess; describe clinical features of pilonidal abscess

A
  • Discharging sinus in intergluteal cleft area
  • Intermittently painful

If pilonidal sinus becomes infected and abscess forms present with mass that is:

  • Erytheamtous
  • Fluctuant
  • Tender
20
Q

Discuss the management of pilonidal sinuses

A

Someties pilonidal disease eases with age & doens’t require surgical management.

Conservative

  • Shaving the affected region
  • Plucking sinus free of any hair

Surgery for chronic disease

  • Excision of tract & layout open of wound
  • Ecxision of tract & primary closure (higher reate reoccurrence, lower infection rate)

Pilonidial abscess:

  • Abx if septic
  • Incision & drainage with washout
  • Removal of sinus at later date
21
Q

What are perianal fistulas?

What are the majority of perianal fistulas associated with?

A
  • Abnormal connection between anal canal and perianal skin
  • Anorectal abscesses

Other risk factors:

  • IBD
  • Systemic disease: TB, HIV
  • History of trauma
  • Previous radiotherapy
22
Q

Describe clinical presentation of anal fistulas

A
  • Present with perianal abscess
  • Discharge onto perineum (mucus, blood, pus or faeces)
  • External opening on the perineum
  • Fibrous tract may be felt underneath skin on DRE
23
Q

What investigations are required for anal fistulas?

A
  • Proctoscopy
  • MRI if complex
24
Q

Discuss the management of perianal fistulas

A

Most fistulas don’t heal on their own. Many surgical methods but most common ones are:

  • Fistulotomy:lay tract open and allow to heal by secondary intention
  • Seton insertion: allows fistula to drain in attempt to let fistula heal and close

May require several repeat procedures

25
Q

What are anal fissures?

State some risk factors

A
  • Tear in mucosal lining of anal anal
  • Risk factors:
    • Constipation
    • IBD
    • Chronic diarrhoea
26
Q

State clinical features of anal fissure

A
  • Intense pain post defecation
    • Can last hours
    • Out of proportion to size of fistula
  • Bleeding (bright red blood when wipe)
  • Itching
  • Visible or palpable fissure on DRE

*NOTE: may need to do DRE under anaesthesia due to pain

27
Q

If pt has fissure within anal canal what would you do to visualise?

A

Proctoscopy

28
Q

Discuss the management of anal fissures, include:

  • Conservative
  • Medical
  • Surgical
A

Conservative

  • Increase fibre
  • Increase fluids
  • Hot baths

Medical

  • Laxatives (passmed says bulk forming are first line)
  • Topical anaesthetics e.g. lidocaine
  • If above doesn’t work (chronic anal fissure) offer GTN or diltazem cream (relaxes internal anal sphincter so puts less pressure on fissure)

Surgical

Reserved for chronic fissures:

  • Botox injections into internal anal sphincter
  • Lateral sphincterotomy

*Main complications of anal fissure surgery = faecal incontinence

29
Q

Where are the anal glands?

A

In the intersphincteric space (between internal and external sphincter)

30
Q

What is an anorectal abscess?

A

Collection of pus in the anal or rectal region

31
Q

Discuss the pathophysiology of anorectal abscesses

A
  • Anal glands secrete mucus to aid passage of faecal matter
  • The anal ducts drain the anal glands in the anal wall
  • Get plugging/blockage of the anal ducts
  • Lead to fluid stasis which predisposes to infection

Common causative organisms: E-coli, Bacteriodes spp, Enterococcus

32
Q

State clinical features of anorectal abscesses

A
  • Pain in perianal region
    • Exacerbated by sitting
  • Localised swelling
  • Itching
  • Discharge
  • Erythematous, fluctuant, tender mass
  • Tenderness on DRe
  • +/- signs & symptoms of systemic infection
33
Q

Discuss the management of anorectal abscesses

A
  • Abx therapy (as per local guidelines)
  • Sufficient analgesia
  • Incision & drainage under GA
    • Followed by proctoscopy to check for any fistula
    • May treat with seton then or at later date
    • Left to heal by secondary intention

Yr3 Surgery: General (13 decks)

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