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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
what are special functional common investigations?
Colonic Transit studies Anorectal manometry Endoanal USS Defecating proctogram/MRI Anoscopy EUA
26
what is pelvic floor dysfunction?
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
27
what is the aetiology of pelvic floor dysfunction?
Child-birth related All other causes: Surgery, abuse, perianal sepsis, LARS, etc
28
who does pelvic floor dysfunction affect?
Predominantly women two groups
29
what are the two broad groups of women affected by pelvic floor dysfunction?
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
what are broad disorders?
Chronic Constipation Faecal Incontinence Mixed disorders Chronic pelvic pain
31
what is chronic constipation?
Difficult or reduced frequency of evacuation
32
what are types of chronic constipation?
Dietary (commonest) Drugs Organic Functional
33
what are organic causes of chronic constipation?
Hirshsprung EDS
34
what is Hirschsprung disease?
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
what is EDS?
Ehlers-Danlos syndromes (EDS) are a group of rare inherited conditions that affect connective tissue
36
what are functional causes of chronic
Slow transit (infrequent) Evacuation related (Common) Combination
37
what are drugs that cause constipation?
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
how do you assess chronic constipation?
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
how do you exclude sinister pathology?
Colonic imaging: Colonoscopy/CT Colon Baseline bloods: Exclude anaemia Symtomatic qFIT Coeliac serology Faecal Calprotectin as appropriately
40
when do you treat chronic constipation?
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
how do you treat chronic constipation?
Start with regular baseline laxatives Ensure compliance Consider combination therapy
42
what are second line drugs for chronic constipation?
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
what second line drugs are used only in women for chronic constipation?
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
what second line drugs are used in all adults for chronic constipation?
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
what second line drugs are used for IBS related constipation?
Linaclotide
46
what are other options rather than medication for chronic constipation?
Peristeen Irrigation system Qufora Irrigation Antegrade irrigation: ACE (falling out of favour)
47
what are surgical options for chronic constipation?
Sigmoid colectomy: Insufficient evidence Subtotal colectomy with end ileostomy Subtotal colectomy with ileorectal anastomosis Trial with ileostomy prior to undertaking major operatinve intervention
48
how is the incidence of faecal incontinence changing?
Increasing incidence with increasing age
48
what are types of faecal incontinence?
Passive: Internal sphincter defect Urge: Rectal pathology, functional Mixed: Prolapse Overflow: Constipation
49
how do you assess faecal incontinence?
Detailed history to determine urge/passive/overflow Obstetric/surgical history ?Trauma/abuse Clinical examination Anorectal physiology Endo-anal USS Defaecatory proctogram
50
what is covered in the clinical assessment of faecal incontinence?
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
anal manometry
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
what are basic measurements from anal manometry?
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
what is RAIR?
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
what is an endoanal USS?
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
what can be seen in a EAUS of the high anal canal in men?
thin arc of mujscles from the deep part of EAS can be seen anteriorly in males
56
what can be seen in a EAUS of the high canal in females?
deep part of EAS not seen anteriorly in females. not to be taken for rupture
57
Defaecating Proctogram
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
what does defaecatinf proctogram provide information on?
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
what are the disadvantages of a dynamic MRI proctogram?
Dynamic MRI Proctogram: More time consuming, expensive, not physiological
60
what is the management options of foecal incontinence?
Aggressive conservative measures Low fibre diet Loperamide Pelvic floor exercises EMG if required Irrigation Anal plug
61
what are the surgical intervemtions for FI?
Sphincter repair Correct anatomical defect Sacral nerve stimulator Anal bulking agent for passive FI Permacol GateKeeper SphinKeeper
62
what are examples of Anal bulking agent for passive FI?
Permacol GateKeeper SphinKeeper
63
what is Rectocoel?
Passive loss of stool from being trapped due to incomplete evacuation
64
what is Internal rectal prolapse?
Symptoms of obstructive defaecation and FI
65
how do you manage mixed disorders such as rectocoel/internal rectal prolapse?
Improve rectal evacuation using different techniques Biofeedback Enemas/Loperamide Surgical intervention
66
how would you assess chronic pelvic pain?
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
who is a pelvic floor MDT?
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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