anorectal🥳 Flashcards
HAEMORRHOIDS what are they?
abnormal swelling or enlargement of anal vascular cushions
HAEMORRHOIDS classification
Classification Description
1st Degree Remain in the rectum
2nd Degree Prolapse through the anus on defecation but spontaneously reduce
3rd Degree Prolapse through the anus on defecation but require digital reduction
4th Degree Remain persistently prolapsed
HAEMORRHOIDS risk factors?
XS straining (from chronic constipation), inc age, raised intra abdo pressure (from what? x3) less common: pelvic/abdo masses, fhx, cardia failure, portal htn
HAEMORRHOIDS clinical fetaures?
painless bright red rectal bleeding - commonly after defecation - on paper or covering pan. *** seen on stool surface, not mixed in!!!
other sx: pruritus (?), rectal fullness/anal lump, soiling (?)
- large prolapsed haemorrhoids can thrombose -> v painful. present to a&e
HAEMORRHOIDS OE?
- normal unless prolapse
- thrombosed prolapsed haemorrhoid? purple/blue, oedematous, tense, perianal mass
HAEMORRHOIDS differentials ?
exclude other causes of rectal bleeding!! eg ca, ibd, diverticular disease
perianal disease to exclude: fistula, fissure, abscess
HAEMORRHOIDS investigations?
- proctoscopy
- bloods - when pt has? x2
- colonoscopy to exclude other pathology before surgical intervention
HAEMORRHOIDS management?
- conservative: lifestyle eg inc daily fibre & fluid to avoid constipation, laxative is needed, topical analgesia (eg?) for pain relief - avoid PO analgesia (why?)
- symptomatic 1&2 degree haemorrhoids treated w rubber band ligation (what is this?)
- surgical: for 2&3 degree = haemorrhoidal artery ligation (what is this?). for 3&4 degree= haemorrhoidectomy (what is this?)
- main comps after surgery??? recurrence, anal structuring, faecal incontinence
PERIANAL FISTULA what is it?
abnormal connection between the anal canal and perianal skin.
they can be inter sphincteric, trans sphincteric, supra sphincteric or extra sphincteric (parks classification system)
PERIANAL FISTULA aetiology?
typically occurs as a consequence of an anorexia abscess
other risk factors: ibd, dm, hx of trauma to anal region, prev radiation to anal region
PERIANAL FISTULA clinical features?
usually present w either recurrent perianal abscesses or intermittent or continuous discharge onto the perineum (inc mucus, blood, pus or faeces)
PERIANAL FISTULA OE?
an external opening onto he perineum may be seen - either be fully open or covered in granulation tissue
fibrous tract may be felt under the skin on dre
PERIANAL FISTULA what is the goodsall rule?
predicts fistula trajectory
- opening behind transverse anal line? fistula curved to midline
- opening in front of transverse anal line? fistula straight to dentate line
PIC ON TMS
PERIANAL FISTULA investigations ?
mri to visualise tract
PERIANAL FISTULA management ?
** definitive depends on cause & site
surgical:
- fistulotomy (for superficial disease) (what is this?)
- seton placement (for high tract disease) (what is this?)
ANORECTAL ABSCESS what is it?
collection of pus in the anal or rectal region
m>f, highrates of recurrence
ANORECTAL ABSCESS pathophysiology ?
plugging of the anal ducts (which normally drain the anal glands in the anal wall - what do these glands help to do?). blocked duct=fluid stasis=infection. most common causative organisms?
- glands are located in intersphincteric space so the infection can spread to adjacent areas. categorisation by area: perianal, ischiorectal, intersphincteric, supralevator
ANORECTAL ABSCESS clinical features?
severe pain in perianal region, worse w direct pressure (eg sat down) alongside potential perianal discharge or bleeding. severe? systemic sx eg fever, rigours, general malaise, or sepsis features
ANORECTAL ABSCESS OE?
erythmatous, fluctuat, tender perianal mass which may discharge pus or have surrounding redness.
deeper? may have no obvious external signs but have SEVERE tenderness on PR
ANORECTAL ABSCESS investigations ?
diagnosis is typically clinical
- bloods - ?
- abscess w/o known fistula or other rectal pathology should be tested for DM w what test?
- atypical presentation? mri pelvis
ANORECTAL ABSCESS management?
- abx
- analgesia
- EUA rectum and incision&drainage all under GA. left to heal by 2 intention ( w or w/o packing)
- intra op proctoscopy
ANAL FISSURE what is it?
tear in the mucosal lining of the anal canal acute = < 6 wks chronic = >6 wks 1 = no underlying disease 2 = underlying disease eg ibd
ANAL FISSURE risk factors?
inflammation or trauma to anal canal, constipation, diarrhoea, ibd, chronic diarrhoea
ANAL FISSURE clinical features
intense pain post defecation - can last several hrs! other sx: bleeding (bright red or wiping), itching
ANAL FISSURE OE?
can be visible and/or palpable on DRE ( pts typically refuse due to pain so EUA may be needed). typically in the posterior midline
ANAL FISSURE differentials?
haemorrhoids, crohns, uc , anal ca
ANAL FISSURE medical management?
- reduce risk factors
- analgesia
- inc fibre & fluid + stool softening laxatives
- topical anaesthetics
- next line: GTN cream or diltiazem cream (how do these work?)
ANAL FISSURE surgical management ?
for chronic issues where med mgmt has failed after 8wks
- botox injections into internal anal sphincter ( how does this work?)
- lateral sphincterotomy
