Anorectal

Question 1

Define haemorrhoids

Answer 1

Abnormal swelling or enlargement of anal vascular cushions

Question 2

Risk factors for haemorrhoids

Answer 2

Excessive straining
Increasing age
Raised intra-abdominal pressure

Question 3

Clinical features of haemorrhoids

Answer 3

Painless bright red rectal bleeding - blood on surface of stool
Pruitus - due to chronic mucus discharge
Rectal fullness
Soiling
Thrombosed - purple, oedematous, tense and tender perianal mass

Question 4

Investigations for haemorrhoids

Answer 4

Proctoscopy

FBC + coagulation screen

Question 5

Management of haemorrhoids

Answer 5

Lifestyle advice
- increasing daily fibre
- increasing fluid intake
- prescribing laxatives
Topical analgesia

Question 6

Non-surgical management of haemorrhoids

Answer 6

Rubber-band ligation - 1st + 2nd degree

Haemorrhoid artery ligation

Question 7

Surgical management of haemorrhoids

Answer 7

Haemorrhoidectomy

Question 8

Complications of haemorrhoids

Answer 8

Thrombosis
Ulceration
Gangrene
Skin tags
Perianal sepsis

Question 9

Define pilonidal sinus disease

Answer 9

Formation of sinus in the cleft of the buttocks

Question 10

How does a pilonidal sinus form?

Answer 10

Hair follicle in intergluteal cleft becomes infected or inflamed
Obstruction of opening of follicle
Foreign body-type reaction
Formation of a cavity

Question 11

Risk factors for pilonidal sinus disease

Answer 11

Caucasian male with coarse dark body hair
Those who sit for long periods of time
Increased sweating
Buttock friction
Obesity
Poor hygiene 
Local trauma

Question 12

Clinical features of pilonidal sinus disease

Answer 12

Intermittent red, painful and swollen mass in sacrococcygeal region
Does not communicate with anal canal - rigid sigmoidoscopy or MRI will show no internal opening of tract

Question 13

Non-surgical management of pilonidal sinus disease

Answer 13

Shaving affected region
Plucking sinus free of hair
Abscess requires surgical drainage and antibiotics

Question 14

Surgical management of pilonidal sinus

Answer 14

Incision and drainage of abscess
For chronic disease removal of pilonidal sinus tract
- excising tract and laying open wounds - allowing closure by secondary intention
- excising tract and primary closure of wound

Question 15

Define a perianal fistula

Answer 15

Abnormal connection between the anal canal and perianal skin

Question 16

Risk factors for perianal fistula

Answer 16

Perianal abcess
IBD
Systemic diseases - TB, diabetes, HIV
History of trauma
Previous radiotherapy

Question 17

Clinical features of perianal fistula

Answer 17

Recurrent perianal abcesses
Continuous discharge onto perineum
External opening on perineum seen on examination
Fibrous tract felt under skin

Question 18

Investigations for perianal fistula

Answer 18

Proctoscopy - visualise opening of tract in anal canal

MRI imaging

Question 19

Surgical management for perianal fistula

Answer 19

Fistulotomy

Seton - bring together fistula and prevent abscess formation

Question 20

Define an anal fissure

Answer 20

Tear in mucosal lining of the anal canal

Question 21

Risk factors for anal fissure

Answer 21

Constipation
Dehydration
IBD
Chronic diarrhoea

Question 22

Clinical features of anal fissure

Answer 22

Intense pain post-defecation
Bleeding
Itching
Visible or palpable on DRE
Many will reject DRE due to intesnse pain - examination under anaesthesia (EUA)

Question 23

Management of anal fissure

Answer 23

Reducing risk factors
Adequate analgesia
Increasing fibre and fluid intake
Stool softening laxatives
GTN cream or diltiazem cream

Question 24

Surgical management of anal fissure

Answer 24

Reserved for chronic fissures
Botox injections
Lateral sphincterotomy

Question 25

Define anorectal abscess

Answer 25

Collection of pus in the anal or rectal region

Question 26

How does an anorectal abscess form?

Answer 26

Plugging of the anal ducts | Fluid ducts leading to infections

Question 27

Causative organisms of an anorectal abscess form

Answer 27

E.coli Bacteriodes spp Enterococcus spp

Question 28

Clinical features of anorectal abscess

Answer 28

Pain in perianal region - exacerbated when sat down Localised swelling, itching and discharge Erythematous, fluctuant, tender mass on examination

Question 29

Management of anorectal abscess

Answer 29

Antibiotic therapy Sufficient analgesia Incision and drainage - heal by secondary intention Proctoscopy to check for fistula-in-ano

Question 30

Define rectal prolapse

Answer 30

Protrusion of mucosal or full-thickness layer of rectal tissue out of anus

Question 31

Risk factors for rectal prolapse

Answer 31

``` Increasing age Female gender Multiple deliveries Straining Anorexia Previous traumatic vaginal delivery ```

Question 32

Clinical features of rectal prolapse

Answer 32

``` Rectal mucus discharge Faecal incontinence Per rectum bleeding Visible ulceration Tenesmus ```

Question 33

Conservative management of rectal prolapse

Answer 33

Increasing dietary fibre and fluid intake | Minor mucosal prolapses may be banded in clinic - prone to recurrence

Question 34

Surgical management of rectal prolapse

Answer 34

Perineal approach - resection | Abdominal approach - laparoscopic rectopexy

Question 35

What is the main type of anal cancer?

Answer 35

Squamous cell carcinoma

Question 36

Define AIN

Answer 36

Anal Intraepithelia Neoplasia Precancerous condition linked to development of squamous cell carcinoma Strongly linked with HPV infection

Question 37

Risk factors for anal cancer

Answer 37

``` HPV infection HIV infection Increasing age Smoking Immunosuppression Crohn’s disease ```

Question 38

Clinical features of anal cancer

Answer 38

``` Rectal pain and bleeding Discharge Pruritus Palpable mass Ulceration and wart-like lesions ```

Question 39

Initial investigation for anal cancer

Answer 39

Proctoscopy EUA - biopsy Smear test to excluse CIN HIV test

Question 40

Imaging for anal cancer

Answer 40

USS-guided fine needle aspiration - palpable inguinal lymph nodes CT thorax-abdomen-pelivs - distant metastases MRI pelvis - extent of local invasion

Question 41

Management of anal cancer

Answer 41

Chemo-radiotherapy Wide local incision Abdominoperineal resection

Question 42

Complication of anal cancer

Answer 42

Chemoradiation-related pelvic toxicity - dermatitis - diarrhoea - proctitis - cystitis