anorectal🥳

Question 1

HAEMORRHOIDS what are they?

Answer 1

abnormal swelling or enlargement of anal vascular cushions

Question 2

HAEMORRHOIDS classification

Answer 2

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

Question 3

HAEMORRHOIDS risk factors?

Answer 3

XS straining (from chronic constipation), inc age, raised intra abdo pressure (from what? x3)
less common: pelvic/abdo masses, fhx, cardia failure, portal htn

Question 4

HAEMORRHOIDS clinical fetaures?

Answer 4

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

Question 5

HAEMORRHOIDS OE?

Answer 5

• normal unless prolapse

- thrombosed prolapsed haemorrhoid? purple/blue, oedematous, tense, perianal mass

Question 6

HAEMORRHOIDS differentials ?

Answer 6

exclude other causes of rectal bleeding!! eg ca, ibd, diverticular disease
perianal disease to exclude: fistula, fissure, abscess

Question 7

HAEMORRHOIDS investigations?

Answer 7

• proctoscopy
• bloods - when pt has? x2
• colonoscopy to exclude other pathology before surgical intervention

Question 8

HAEMORRHOIDS management?

Answer 8

• 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

Question 9

PERIANAL FISTULA what is it?

Answer 9

abnormal connection between the anal canal and perianal skin.
they can be inter sphincteric, trans sphincteric, supra sphincteric or extra sphincteric (parks classification system)

Question 10

PERIANAL FISTULA aetiology?

Answer 10

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

Question 11

PERIANAL FISTULA clinical features?

Answer 11

usually present w either recurrent perianal abscesses or intermittent or continuous discharge onto the perineum (inc mucus, blood, pus or faeces)

Question 12

PERIANAL FISTULA OE?

Answer 12

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

Question 13

PERIANAL FISTULA what is the goodsall rule?

Answer 13

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

Question 14

PERIANAL FISTULA investigations ?

Answer 14

mri to visualise tract

Question 15

PERIANAL FISTULA management ?

Answer 15

** definitive depends on cause & site
surgical:
- fistulotomy (for superficial disease) (what is this?)
- seton placement (for high tract disease) (what is this?)

Question 16

ANORECTAL ABSCESS what is it?

Answer 16

collection of pus in the anal or rectal region

m>f, highrates of recurrence

Question 17

ANORECTAL ABSCESS pathophysiology ?

Answer 17

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

Question 18

ANORECTAL ABSCESS clinical features?

Answer 18

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

Question 19

ANORECTAL ABSCESS OE?

Answer 19

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

Question 20

ANORECTAL ABSCESS investigations ?

Answer 20

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

Question 21

ANORECTAL ABSCESS management?

Answer 21

• abx
• analgesia
• EUA rectum and incision&drainage all under GA. left to heal by 2 intention ( w or w/o packing)
• intra op proctoscopy

Question 22

ANAL FISSURE what is it?

Answer 22

tear in the mucosal lining of the anal canal 
acute = < 6 wks
chronic = >6 wks 
1 = no underlying disease 
2 = underlying disease eg ibd

Question 23

ANAL FISSURE risk factors?

Answer 23

inflammation or trauma to anal canal, constipation, diarrhoea, ibd, chronic diarrhoea

Question 24

ANAL FISSURE clinical features

Answer 24

intense pain post defecation - can last several hrs! other sx: bleeding (bright red or wiping), itching

Question 25

ANAL FISSURE OE?

Answer 25

can be visible and/or palpable on DRE ( pts typically refuse due to pain so EUA may be needed). typically in the posterior midline

Question 26

ANAL FISSURE differentials?

Answer 26

haemorrhoids, crohns, uc , anal ca

Question 27

ANAL FISSURE medical management?

Answer 27

• reduce risk factors
• analgesia
• inc fibre & fluid + stool softening laxatives
• topical anaesthetics
• next line: GTN cream or diltiazem cream (how do these work?)

Question 28

ANAL FISSURE surgical management ?

Answer 28

for chronic issues where med mgmt has failed after 8wks

• botox injections into internal anal sphincter ( how does this work?)
• lateral sphincterotomy