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Alimentary System > Anorectal and Pelvic floor disorders > Flashcards

Anorectal and Pelvic floor disorders Flashcards

1
Q

what is the function of the anorectum?

A

Control of defaecation
Maintenance of continence

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2
Q

what does the function of anorectum require?

A

Pelvic floor
Rectal Compliance
Intact pelvic neurology

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3
Q

what are the different compartements of the anorectum?

A
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4
Q

what are symptoms of haemorrhoids?

A

painless bleeding from anus

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5
Q

what is haemorrhoids typically caused by?

A

straining

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6
Q

what is the treatment for haemorrhoids?

A

treat underlying cause - constipation
OPD: RBL - rubber band ligation

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7
Q

what are the surgical treatments available for haemorrhoids?

A

HALO
Anopexy
HAemorrhoidectomy

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8
Q

what is an anal fissure?

A

An anal fissure is a tear or open sore (ulcer) that develops in the lining of the large intestine, near the anus

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9
Q

what are the symptoms of anal fissures?

A

pain
bleeding - characterised like glass splinters

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10
Q

what are the treatment options available for anal fissures?

A

underlying cause - constipation
medical management
surgical management

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11
Q

what is the medical management for anal fissures?

A

GTN/Diltiazem + Lignocaine

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12
Q

what are the surgical treatment options available for anal fissures?

A

Botox
Sphincterotomy

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13
Q

what do patients with anal fissures/fistulas have increased risk of?

A

anorectal cancer

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14
Q

what is a perianal absess?

A

A perianal abscess is a type of anorectal abscess that is confined to the perianal space.

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15
Q

what are symptoms of a perianal abscess?

A

excrutiating pain
signs of sepsis

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16
Q

what are risk factors for a perianal abscess?

A

DM, BMI, Immunosuppression, trauma

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17
Q

what is treatment for a peri-anal abscess?

A

Abx if septic
Incision and drainage
Do not go looking for fistulas

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18
Q

what is a fistula in ano?

A

tunnel that develops between the inside of the anus and the outside skin around the anus, occur after anal abscess

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19
Q

what are symptoms of fistula in ano?

A

Peri-anal sepsis
Persisting pus discharge with flare up
+/- fecal soiling

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20
Q

what is the treatment for fistula in ano?

A

Very difficult to treat
Surgical: 50% failure rate [wanting to preserve sphincter]
Seton – to drain sepsis/mature tract
Sphincter preservation techniques

Lay open: BEWARE Women

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21
Q

what is anal/rectal cancer?

A

Anal cancer is an uncommon type of cancer that occurs in the anal canal.

Rectal cancer is cancer that begins in the rectum.

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22
Q

what are symptoms of anal/rectal cancer?

A

Painful/painless
Bleeding
Indurated (hardened)

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23
Q

what must you look out for in possible diagnosis of anal/rectal cancer?

A

Red flag signs
FIT test +ve (still may not be cancer, it being negative may indicate cancer is more proximal)

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24
Q

what are routine investigations?

A

PR examination
Proctoscopy
Rigid sigmoidoscopy
Colonoscopy/flexi sigmoidoscopy
CT colonoscopy
CT scan
MRI rectum

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25
Q

what are special functional common investigations?

A

Colonic Transit studies
Anorectal manometry
Endoanal USS
Defecating proctogram/MRI
Anoscopy
EUA

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26
Q

what is pelvic floor dysfunction?

A

Collection of wide spectrum of symptoms related to defecation
Obscure symptomatology
Often a fear of more serious illnesses
Patients often haven’t completely understood their own symptoms
Embarrassment and hesitation to come up with real issues
May have a history of abuse
Social limitation

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27
Q

what is the aetiology of pelvic floor dysfunction?

A

Child-birth related

All other causes: Surgery, abuse, perianal sepsis, LARS, etc

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28
Q

who does pelvic floor dysfunction affect?

A

Predominantly women
two groups

29
Q

what are the two broad groups of women affected by pelvic floor dysfunction?

A

Parous women
Largest group
Symptoms related to pregnancy and childbirth

All other patients including men, non-parous women
Surgical misadventure
Neurological/connective tissue disorders
Psychological/behavioural issues

30
Q

what are broad disorders?

A

Chronic Constipation
Faecal Incontinence
Mixed disorders
Chronic pelvic pain

31
Q

what is chronic constipation?

A

Difficult or reduced frequency of evacuation

32
Q

what are types of chronic constipation?

A

Dietary (commonest)
Drugs
Organic
Functional

33
Q

what are organic causes of chronic constipation?

A

Hirshsprung
EDS

34
Q

what is Hirschsprung disease?

A

Hirschsprung disease is a birth defect in which some nerve cells are missing in the large intestine, so a child’s intestine can’t move stool and becomes blocked.

35
Q

what is EDS?

A

Ehlers-Danlos syndromes (EDS) are a group of rare inherited conditions that affect connective tissue

36
Q

what are functional causes of chronic

A

Slow transit (infrequent)
Evacuation related (Common)
Combination

37
Q

what are drugs that cause constipation?

A

Aluminium antacids
Antimuscarinics (e.g. procyclidine, oxybutynin)
Antidepressants (most commonly tricyclic antidepressants, but others may cause constipation in some individuals)
Antiepileptics (e.g. carbamazepine, gabapentin, oxcarbazepine, pregabalin, phenytoin) Sedating antihistamines
Antipsychotics
Antispasmodics (e.g. dicycloverine, hyoscine)
Calcium supplements
Diuretics
Iron supplements
Opioids
Verapamil

38
Q

how do you assess chronic constipation?

A

Exclude sinister pathology
Detailed history including dietary to establish type of constipation
Colonic transit studies
Defecating proctogram
May need more investigations to exclude hirshsprung/EDS

39
Q

how do you exclude sinister pathology?

A

Colonic imaging: Colonoscopy/CT Colon
Baseline bloods: Exclude anaemia
Symtomatic qFIT
Coeliac serology
Faecal Calprotectin as appropriately

40
Q

when do you treat chronic constipation?

A

Most patients usually want sinister pathology excluded
Aggressive dietary management
Ensure adequate water intake (not just fluids/fizzy drinks)
Caffeinated coffee
Biofeedback for learning/relearning toileting habits/posture
Good trial of conservative measures and life style optimisation

41
Q

how do you treat chronic constipation?

A

Start with regular baseline laxatives
Ensure compliance
Consider combination therapy

42
Q

what are second line drugs for chronic constipation?

A

Proculopride for women only: Failed tx with 2 or more regular laxatives from different classes at highest dose for 6 months and invasive measures considered

Lubiprostone for all adults: Failed tx with 2 or more regular laxatives from different classes at highest dose for 6 months and invasive measures considered

Linaclotide: For IBS related constipation

43
Q

what second line drugs are used only in women for chronic constipation?

A

Proculopride for women only: Failed tx with 2 or more regular laxatives from different classes at highest dose for 6 months and invasive measures considered

44
Q

what second line drugs are used in all adults for chronic constipation?

A

ubiprostone for all adults: Failed tx with 2 or more regular laxatives from different classes at highest dose for 6 months and invasive measures considered

45
Q

what second line drugs are used for IBS related constipation?

A

Linaclotide

46
Q

what are other options rather than medication for chronic constipation?

A

Peristeen Irrigation system
Qufora Irrigation
Antegrade irrigation: ACE (falling out of favour)

47
Q

what are surgical options for chronic constipation?

A

Sigmoid colectomy: Insufficient evidence
Subtotal colectomy with end ileostomy
Subtotal colectomy with ileorectal anastomosis
Trial with ileostomy prior to undertaking major operatinve intervention

48
Q

how is the incidence of faecal incontinence changing?

A

Increasing incidence with increasing age

48
Q

what are types of faecal incontinence?

A

Passive: Internal sphincter defect
Urge: Rectal pathology, functional
Mixed: Prolapse
Overflow: Constipation

49
Q

how do you assess faecal incontinence?

A

Detailed history to determine urge/passive/overflow
Obstetric/surgical history
?Trauma/abuse
Clinical examination
Anorectal physiology
Endo-anal USS
Defaecatory proctogram

50
Q

what is covered in the clinical assessment of faecal incontinence?

A

Peri-anal skin: excoriation/soiling/lesions

Perineal descent of bearing down: mild/moderate/severe; ?Prolapse

Resting anal sphincter tone: Normal/reduced tone/lax sphincter

Squeeze increment: negligible/reduced/good

Rectocoel

Paradoxical contraction pubirectalis

Proctoscope/Rigid sigmoidoscope: Mucosal prolapse/Haemorrhoids/Intussusception

Middle compartment prolapse

51
Q

anal manometry

A

Anorectal manometry is a test performed to evaluate patients with anorectal sphincter disorders. This test measures the pressures of the anal sphincter muscles, the sensation in the rectum, and the neural reflexes that are needed for normal bowel movements

52
Q

what are basic measurements from anal manometry?

A

Anal sphincter function: Resting pressure, squeeze increment, Duration of squeeze

Estimation of functional length of anal canal

Anorectal pressure responses during abrupt increases in IAB: eg cough

Changes in anal pressure during defaecation

Recto-anal inhibitory reflex (RAIR): Rectal distension – IS relaxation – Sampling by anal mucosa – consistency – need for evacuation

For detection of congenital Hirshsprung
Systemic sclerosis

53
Q

what is RAIR?

A

Rectoanal inhibitory reflex (RAIR) is routinely assessed in anorectal manometry and is of clinical value in the diagnosis of patients with constipation.

The lack of this reflex in patients with chronic constipation may suggest Hirschsprung disease

54
Q

what is an endoanal USS?

A

Endo anal ultrasound scan involves taking ultrasound pictures of the rectum and anus.

indications for endoanal ultrasound have been anal carcinoma, perirectal or perianal fistulas, perianal abscesses and sphincter insufficiencies.

55
Q

what can be seen in a EAUS of the high anal canal in men?

A

thin arc of mujscles from the deep part of EAS can be seen anteriorly in males

56
Q

what can be seen in a EAUS of the high canal in females?

A

deep part of EAS not seen anteriorly in females.
not to be taken for rupture

57
Q

Defaecating Proctogram

A

The physician will inject a barium paste — about the consistency of toothpaste — through a tube into your rectum. You will then be asked to sit on a special toilet, which will allow images to be taken during the process of defecation. Images and video will be taken with a fluoroscope, a type of moving-picture X-ray.

Best modality to assess anatomy and dynamic function

58
Q

what does defaecatinf proctogram provide information on?

A

Pelvic floor mobility
Pathological function of the musculature
Changes to form and axis of organs (Deformation and morphology)
Compensated/decompensated function
Internal hernias (enterocoel)

59
Q

what are the disadvantages of a dynamic MRI proctogram?

A

Dynamic MRI Proctogram: More time consuming, expensive, not physiological

60
Q

what is the management options of foecal incontinence?

A

Aggressive conservative measures
Low fibre diet
Loperamide
Pelvic floor exercises
EMG if required
Irrigation
Anal plug

61
Q

what are the surgical intervemtions for FI?

A

Sphincter repair
Correct anatomical defect
Sacral nerve stimulator

Anal bulking agent for passive FI
Permacol
GateKeeper
SphinKeeper

62
Q

what are examples of Anal bulking agent for passive FI?

A

Permacol
GateKeeper
SphinKeeper

63
Q

what is Rectocoel?

A

Passive loss of stool from being trapped due to incomplete evacuation

64
Q

what is Internal rectal prolapse?

A

Symptoms of obstructive defaecation and FI

65
Q

how do you manage mixed disorders such as rectocoel/internal rectal prolapse?

A

Improve rectal evacuation using different techniques
Biofeedback
Enemas/Loperamide
Surgical intervention

66
Q

how would you assess chronic pelvic pain?

A

Complex patients with multiple behavioural/psychological issues
Determine cause of pain
Simple measures: EUA, pudendal nerve block, regular enemas/suppositories
Is it positional?
Often challenging patients
Be empathetic
Refer to a colleague who has a special interest

67
Q

who is a pelvic floor MDT?

A

Each centre with a pelvic floor practice must have a Local MDT
There are regional MDTs in Scotland
Every patient failing conservative therapy must go through a local MDT
Especially if interventions involving mesh/implants
Multi-compartment symptoms to be managed in an MDT setting
MDT members: Colorectal, Gynaecology, Urology, Radiology, Biofeedback team
Mesh related complication: Refer to regional mesh removal centres

Alimentary System (44 decks)

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