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GI AND SURGERY > ANORECTAL DISEASE > Flashcards

ANORECTAL DISEASE Flashcards

1
Q

What is an anal fissure?

A

a tear or ulcer in the lining of the anal canal

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2
Q

Where do anal fissures most commonly occur?

A

posterior midline of the anal canal.
If not here then consider other underlying causes e.g. crohns
(Midline 6&12 o’clock)

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3
Q

How do we classify anal fissures?

A

Acute — if present for less than 6 weeks.
Chronic — if present for 6 weeks or longer.
Primary — if there is no clear underlying cause.
Secondary — if there is a clear underlying cause.

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4
Q

What can cause secondary anal fissures?

A

Constipation/passage of hard stools
Conditions which can cause ulceration of the anal mucosa such as: IBD, STIs, colorectal cancer, derm conditions e.g. psoriasis and pruritis ani, skin infections
anal trauma (surgery/sex)
adverse drug effects,
Pregnancy and childbirth

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5
Q

Where do we tend to see anal fissures caused by childbirth?

A

anterior midline.

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6
Q

What are the risk factors of anal fissures?

A

IBD
Constipation
STIs - HIV, syphilis, herpes
Low fibre diet
Diarrhoea
Previous anal surgery
Anal trauma
Abnormalities of internal anal sphincter

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7
Q

What are the complications of an anal fissure?

A

Failure to heal/progression to chronic fissure.
Recurrent fissure.
Anorectal fistula.
Infection/abscess.
Faecal impaction if avoiding defecation due to pain
Reduced quality of life due to pain (especially in chronic cases)

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8
Q

What are the symptoms and signs of an anal fissure?

A

Sharp, severe anal pain always occurs with passing a stool followed by deep burning pain that persists for several hours.
Small amount of bleeding may occur with defecation
A tearing sensation on passing stool
Midline tear

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9
Q

How do acute and chronic anal fissures compare on inspection?

A

Acute anal fissures- superficial with well-demarcated edges.
Chronic anal fissures - wider and deeper with muscle fibres visible in the base. The edges are often swollen, and a skin tag may be visible at the end of the fissure.

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10
Q

How do primary and secondary anal fissures compare on inspection?

A

Primary anal fissures - usually singular and occur in the posterior midline of the anus (although a few cases may be seen in the anterior midline;especially in women).
Secondary anal fissures - may have an irregular outline, be multiple, or occur laterally — these require further investigation to identify the underlying cause

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11
Q

What should you consider if a child has an anal fissure and other possible causes have been excluded?

A

Sexual abuse

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12
Q

What are the differential diagnoses of anal fissures?

A

Thrombosed haemorrhoids
Inflammatory bowel disease.
Sarcoidosis.
Infection for example tuberculosis, HIV, or syphilis.
Malignancy for example anal carcinoma or lymphoma.
Peri-anal abscess.

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13
Q

What are thrombosed haemorrhoids
How do they present?

A

when a blood clot forms inside a hemorrhoidal vein, obstructing blood flow and causing a painful swelling of the anal tissues.

pain sitting, walking, or going to the toilet to pass a stool.
itching around the anus.
bleeding when passing a stool.
swelling or lumps around the anus.

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14
Q

How do we treat anal fissures?

A

If cancer is suspected then consider need for 2WW referral or other appropriate specialist if another serious underlying cause is suspected
If acute…
Ensure stools are soft and easy to pass - advice on dietary fibre, adequate fluid intake and bulk forming laxatives. Try petroleum jelly before defecation.
Hygiene - anal region clean and dry to aid healing and avoid complications
Advise against stool withholding
Manage pain - NSAIDs, warm baths particularly after a bowel movement, maybe topical anaesthetic for use before passing a stool e.g. lidocaine

Chronic:
Above continue
GTN topical for 8 weeks
If not effective then consider spincterotomy or botulinum toxin

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15
Q

What should you think if an elderly person presents with anal fissures?

A

Likely to be colorectal cancer

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16
Q

How should you manage an adult with a primary anal fissure who has had symptoms for 1 week or more without improvement?

A

Consider prescribing rectal GTN ointment twice a day for 6-8 weeks

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17
Q

Whats the main side effect of GTN ointment?

A

25% experience headaches

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18
Q

What follow-up advice should be offered for those undergoing management for primary anal fissures?

A

In a child, advise the parents/carers to return if the fissure is unhealed after 2 weeks, or earlier if the child is in a lot of pain.
In an adult, review if the fissure is unhealed after 6–8 weeks, or earlier if needed
Advise all people that they should continue with the dietary and lifestyle measures when the fissure has healed to reduce the risk of recurrence.

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19
Q

What is pruritis ani?

A

Itchy bottom that causes perianal excoriation

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20
Q

What typically causes pruritus ani?

A

Primary - idiopathic, faecal contamination
Secondary - skin conditions (contact dermatitis, atopic eczema, lichen plants etc…), infections (including parasites), colorectal and anal pathology, systemic diseases, psychological disorders, systemic and topical drugs, certain foods and drinks, certain clothings and detergents

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21
Q

Whats the management of pruritis ani?

A

Enhancing toilet hygiene
Avoiding foods and drinks that aggravate it
Avoid scratching
Considering a cotton wool plug to soften faeces leaking from anus during exercise
Keeping area dry and avoiding use of perfumed moisturising creams
Avoid straining and mechanical irritation
Advise about dietary fibre and fluid intake
Manage any constipation

Soothing creams or ointments containing zinc oxide (some find Vaseline useful)
Mildly potent topical corticosteroid if skin is inflamed
Sedating antihistamine if disturbed sleep due to nocturnal itching

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22
Q

What are haemorrhoids?

A

abnormally swollen vascular mucosal cushions in the anal canal

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23
Q

What are the vascular mucosal cushions?

A

Submucosal cushions of vascular tissue that help maintain anal continence
They are typically present at 3, 7 and 11 o’clock but there is individual variation - left lateral, right posterior and right anterior portions of anal canal

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24
Q

What is the dentate line and where is it?

A

It’s a line that marks the transition between the upper and lower anal canal
It is situated 2cm from the anal verge

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25
Q

What are external haemorrhoids?

A

originate below the dentate line and are covered by modified squamous epithelium (anoderm), which is richly innervated with pain fibres.
External haemorrhoids can therefore be itchy and painful.

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26
Q

What are internal haemorrhoids?

A

arise above the dentate line and are covered by columnar epithelium, which have no pain fibres. Internal haemorrhoids are therefore not sensitive to touch, temperature, or pain (unless they become strangulated).

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27
Q

How are internal haemorrhoids graded?

A

By degree of prolapse

First degree (Grade 1) — haemorrhoids project into the lumen of the anal canal but do not prolapse.
Second degree (Grade 2) — haemorrhoids protrude beyond the anal canal on straining but spontaneously reduce when straining is stopped.
Third degree (Grade 3) — haemorrhoids protrude outside the anal canal and reduce fully on manual pressure.
Fourth degree (Grade 4) — haemorrhoids protrude outside the anal canal and cannot be reduced.

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28
Q

What are the predisposing factors for haemorrhoids?

A

Constipation
Straining while trying to pass stools
Ageing
Conditions that cause raised intraabdominal pressure
Chronic cough
Heavy lifting
Exercise
Hereditary factors
Low fibre diet

(These factors lead to increased pressure within the submucosal arteriovenous plexus and ultimately contribute to swelling of the cushions, laxity of the supporting connective tissue, and protrusion into and through the anal canal)

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29
Q

What are the complications of haemorrhoids?

A

Perianal thrombosis.
Incarceration of prolapsing haemorrhoidal tissue
Ulceration — from thrombosis of external haemorrhoids.
Skin tags — from repeated episodes of haemorrhoid dilatation and thrombosis.
Maceration of the perianal skin — due to mucus discharge.
Ischaemia, thrombosis, or gangrene in fourth degree internal haemorrhoids
Anal stenosis.
Perianal or pelvic sepsis (rare).
Anaemia from continuous or excessive bleeding (rare).

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30
Q

What proportion of those with haemorrhoids will require surgery to alleviate their symptoms?

A

About 10%
(Recurrence rate after surgery is 13%)

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31
Q

What are the sympotms of haemorrhoids?

A

Bright red PAINLESS rectal bleeding
Anal itching/irritation
Feeling of rectal fullness or tenesmus
Soiling
Pain (mostly with thrombosed external haemorrhoids)

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32
Q

How are haemorrhoids diagnosed?

A

Visual inspection
Anoscopy for internal haemorrhoids
Digital rectal exam

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33
Q

Who with haemorrhoids should you consider there need for urgent admission or referral?

A

Consider admitting people with:
Extremely painful, acutely thrombosed external haemorrhoids who present within 72 hours of onset (reduction or excision may be needed).
Internal haemorrhoids which have prolapsed and become swollen, incarcerated, and thrombosed (haemorrhoidectomy may be needed).
Perianal sepsis (a rare but life-threatening complication).

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34
Q

How should you manage haemorrhoids?

A

Ensure stools are soft and easy to pass - advice on fibre and fluids
Lifestyle advice on correct anal hygiene and avoiding stool withholding
Simple analgesia or a topical haemorrhoids l preparation for symptomatic relief

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35
Q

What treatment is available for haemorrhoids in secondary care?

A

Rubber band ligation
Injection scleropathy
Infrared coagulation
Bipolar diathermy and direct-current electro therapy
Haemorrhoidectomy
Stapled haemorrhoidectomy
Haemorrhoidal artery ligation

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36
Q

What is rubber band ligation?

A

A band is applied to the base of the haemorrhoid. The strangulated haemorrhoid becomes necrotic and sloughs off. The underlying tissue undergoes fixation by fibrotic wound healing. Up to three haemorrhoids can be banded at one visit.

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37
Q

What is injection sclerotherapy?

A

Oily phenol is injected into the submucosa of the rectum, around the pedicles of the haemorrhoids. It induces a fibrotic reaction which obliterates the haemorrhoidal vessels, causing atrophy of the haemorrhoids.

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38
Q

What is infrared coagulation?

A

This involves using infrared energy to produce an area of submucosal fibrosis leading to mucosal fixation and a reduction in the tendency to prolapse.

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39
Q

What is bipolar diathermy and direct-current electro therapy?

A

A probe with metal contact points is placed at the base of the haemorrhoid above the dentate line and a direct electric current is delivered. The aim of the direct current application is to cause thrombosis of the feeding vessels and to cause the haemorrhoid to shrink.

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40
Q

What is a haemorrhoidectomy?

A

an operation to remove severe haemorrhoids

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41
Q

What is a stapled haemorrhoidectomy?

A

A circular stapling gun is used to excise a doughnut of mucosa from the upper anal canal and lift the haemorrhoidal cushions back within the canal.

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42
Q

What is haemorrhoidal aretry ligation?

A

Using a proctoscope, the haemorrhoidal arteries are ligated with sutures (above the dentate line) to remove the flow of blood to the haemorrhoids

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43
Q

What is a fistula?

A

an abnormal connection between an organ, vessel, or intestine and another organ, vessel or intestine, or the skin.

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44
Q

What can cause an anal fistula?

A

After an anal abscess or previous ano-rectal sepsis

Less common causes of anal fistulas include:
IBD - mainly perianal Crohn’s disease
diverticulitis
hidradenitis suppurativa
infection with Tb or HIV
Trauma or previous radiation therapy
a complication of surgery near the anus

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45
Q

How does an anal abscess lead to an anal fistula?

A

After an abscess has been drained, a tunnel may persist connecting the anal gland from which the abscess arose to the skin.

46
Q

What are the 4 types of anal fistulas? What is this classification called?

A

Intersphincteric 45%
Transsphincteric 30%
Supraspincteric 20%
Extrasphincteric 5%

Parks classification system

47
Q

What is an intersphincteric fistula?

A

When the fistula penetrates through the internal sphincter but spares th external sphincter

48
Q

What is a transpshincteric fistula?

A

When the fistula passes through both the internal and external sphincters

49
Q

What is a suprasphincteric fistula?

A

When the fistula penetrates through the internal sphincter and then extends superiority in the plane between the sphincters to pass above the external sphincter before extending to the perineum
This includes a horseshoes abscess

50
Q

What is an extrasphincteric fistula?

A

Very rare
Forms a connection from the rectum to the perineum and extends laterally to the internal and external sphincter

51
Q

What are the signs and symptoms of an anal fistula?

A

skin irritation around the anus
a constant, throbbing pain that may be worse when you sit down, move around, poo or cough
smelly discharge from near your anus
passing pus or blood when you poo
swelling and redness around your anus and a high temperature if you also have an abscess
difficulty controlling bowel movements (bowel incontinence) in some cases
Recurrent perianal abscess

52
Q

How is an anal fistula diagnosed?

A

Anal examination
Proctoscopy
Endoanal ultrasonography, MRI or CT

53
Q

How are fistulas managed?

A

Fistulotomy
Seton techniques
Advancement flap procedure
LIFT procedure
Endoscopic ablation
Laser surgery
Fibrin glue
Bioprosthetic plug

54
Q

What is a fistulotomy?

A

The most common and most effective type of surgery for an anal fistula

This involves cutting along the whole length of the fistula to open it up so it heals as a flat scar

55
Q

When can a fistulotomy not be used?

A

For fistulas that pass through much of the sphincter muscles as the risk of incontinence is too high

56
Q

What are seton techniques?

A

When a surgeon inserts a seton which is a piece of surgical thread that’s left in the fistula for several weeks to keep it open. This allows it to drain and helps it heal, while avoiding the need to cut the sphincter muscles.

57
Q

When are seton techniques used for managing anal fistulas?

A

If the fistula passes through a significant portion of the anal sphincter muscle

58
Q

What is the Goodsall rule?

A

A rule used clinically to predict the trajectory of a fistula tract dependant on the location of the external opening

If external opening is posterior to the transverse anal line then the fistula will follow a curved course to the posterior midline
If external opening is anterior to the transverse anal line, the fistula tract will follow a straight radial course to the dentate line

59
Q

What is an anorectal abscess?

A

a collection of pus in the anal or rectal region.

60
Q

Who are anorectal abscesses more common in?

A

Men

61
Q

What proportion of those with an anorectal abscess have an associated perianal fistula at the time of presentation?

A

1/3rd

62
Q

Whats the pathophysiology of anorectal abscess?

A

Plugging of anal ducts which drain the anal glands in the anal wall = fluid stasis = infection = spreads to adjacent areas

63
Q

What are the common causative organisms of anorectal abscesses?

A

E.coli
Bacteriodes spp
Enterococcus spp

64
Q

What are anal glands found?

A

In the interspincteric space i.e. between the internal and external anal sphincters

65
Q

What are the 4 types of anorectal abscesses and which is most common?

A

Perianal - most common - just beneath the skin of the anal canal
Ischiorectal - in ischiorectal space
Intersphincteric - between internal and external anal sphincters
Supralevator - above levator ani

66
Q

What are the clinical features of an anorectal abscess?

A

Severe pain in perianal region which is worse with direct pressure
Perianal discharge or bleeding
If severe they may have systemic features - fevers, rigors, general malaise, clinical features of sepsis
Erythematous, fluctuating, tender perianal mass which may be discharging pus or have surrounding erythema
Severe tenderness on PR examination

67
Q

What investigations should be done for a perianal abscess?

A

Routine blood
HbA1c to check for diabetes mellitus
Imaging

68
Q

How are perianal abscesses treated?

A

May resolve without treatment if small. Warm compress may help reduce pain and swelling
Antibiotic therapy
Sufficient analgesia
Intra-operative proctoscopy
Drainage of abscess

69
Q

What is pilonidal sinus disease?

A

Disease of the intergluteal region characterised by the formation of a sinus in the cleft of the buttocks

70
Q

Who does pilonidal sinus disease typically affect??

A

Males 16-30

71
Q

Whats the pathophysiology of pilonidal sinus disease?

A

Hair follicle in the intergluteal cleft becomes infected or inflamed = inflammation obstructs the opening of the follicle = follicle extends inwards forming a pit = formation of a cavity that connects to the surface of the skin by an epithelialised sinus tract

72
Q

What are the risk factors for pilonidal sinus disease?

A

Caucasian
Male
Coarse dark body hair
Those who sit for prolonged periods e.g. lorry drivers/office workers
Increased sweating
Buttock friction
Obesity
Poor hygiene
Local trauma

73
Q

What are the clinical features of pilonidal sinus disease?

A

Discharging and intermittently painful sinus in the sacrococcygeal region
May present as a pilonidal abscess if the sinus becomes infected

74
Q

Whats the main distinguishing feature between pilonidal sinus disease and perianal fistula?

A

pilonidal sinus does not communicate with the anal canal

75
Q

Whats the management of pilonidal sinus disease ?

A

Conservative - shave affected region and pluck the sinus free of any hair that is embedded
Antibiotics/surgical drainage if needed for an abscess
Surgery for removing pilonidal sinus tract - (excision and laying open, excision and primary closure, excision and advancement flaps, excision and rotational flaps )

76
Q

What is rectal prolapse?

A

protrusion of mucosal or full-thickness layer of rectal tissue out of the anus

77
Q

Who does rectal prolapse typically affect?

A

Relatively uncommon
Older females

78
Q

What are the main 2 types of rectal prolapse?

A

Partial thickness – the rectal mucosa protrudes out of the anus
Full thickness – the rectal wall protrudes out the anus

79
Q

Whats the pathophysiology of a full anal prolapse?

A

A form of sliding hernia through a defect of the fascia of the pelvic region - may be caused by chronic straining secondary to constipation, chronic cough, multiple vaginal deliveries

80
Q

Whats the pathophysiology of a partial thickness anal prolapse?

A

associated with the loosening and stretching of the connective tissue that attaches the rectal mucosa to the remainder of the rectal wall.
This often occurs in conjunction with long standing haemorrhoidal disease.

81
Q

What are the main risk factors for rectal prolapse?

A

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

82
Q

What are the clinical features of rectal prolapse?

A

Rectal mucus discharged
Faecal incontinence
PR bleeding
Visible ulceration
Sensation of rectal fullness, tenesmus

O/E - visible when asking pt to strain. On PR exam a weakened anal sphincter may be identified

83
Q

How is rectal prolapse managed?

A

Conservative - increase dietary fibre and fluid intake. Minor mucosal prolapses may be banded in clinic
Surgical repair - only definitive management

84
Q

What proportion of colorectal cancers are anal cancers?

A

4%

85
Q

What type are most anal cancerS?

A

Squamous cell carcinomas - arise from below the dentate line
10% are Adenocarcinomas which arise from the upper anal canal epithelium and crypt glands
Rare - melanomas and anal skin cancers

86
Q

What pre-cancerous condition may precede the development of invasive squamous anal carcinoma?

A

Anal intraepithelial neoplasia

87
Q

What is Anal intraepithelial neoplasia?

A

a precancerous condition that can affect either the perianal skin or anal canal, linked to the development of squamous cell carcinoma.
It is strongly linked to infection with the human papilloma virus (HPV).

88
Q

What are risk factors for anal cancer?

A

HPV infection
HIV infection
Increasing age
Smoking
Immunosuppression
Crohns disease

89
Q

What proportion of anal cancers do HPV infections account for?

A

80-90%

90
Q

What are the high-risk types of HPV for anal cancer?

A

HPB-16 and HPV-18

91
Q

What are the clinical features of anal cancer?r

A

ECT all pain
Rectal bleeding
Others - anal discharge, pruritus, palpable mass
Ulceration/wart like lesions
Inguinal lymphadenopathy

92
Q

Whats the lymph drainage from the anal region?

A

Lymph from the area below the dentate line drains to the superficial inguinal nodes
The anal canal and rectum above the dentate line drain into the mesorectal, para-aortic, and paravertebral nodes.

93
Q

What investigations are done for anal cancer?

A

Examination
Proctoscopy
Biopsy
Smear test to exclude any cervical intraepithelial neoplasia
HIV test ??

Once diagnosis confirmed by biopsy…
USS-guided fine needle aspiration of any palpable inguinal lymph nodes
CT thorax-abdomen-pelvis for distant mets
MRI pelvis to assess extent of local invasion

94
Q

How is anal cancer managed?

A

Chemoradiotherapy
Surgical excision if advance disease or failure of above (abdominoperineal resection)

95
Q

Whats the most common complications of anal cancer?

A

Chemoradiation-related pelvic toxicity is the most common short term complication, which can present with dermatitis, diarrhoea, proctitis, and/or cystitis.

Longer term - fertility issues, faecal incontinence, vaginal dryness, erectile dysfunction, rectovaginal fistila

96
Q

Whats the 5 year survival rate of anal cancer tumour stage 1 vs stage 5?

A

Stage 1 - 70%
Stage 5 - 15%

97
Q

What is SRUS?

A

Solitary rectal ulcer syndrome

98
Q

What is solitary rectal ulcer syndrome?

A

a rare and poorly understood disorder where 1 or more ulcers develop in the rectum
often occurs in people with chronic constipation
It can cause rectal bleeding and straining during bowel movements

99
Q

what diseases put you at risk from perianal diseases

A

IBD
Diabetes
Diverticulitis
HIV/AIDS
STIs - HPV and HIV
Trauma
TB

100
Q

Whats the management for thrombosed haemorrhoids?

A

if patient presents within 72 hours then referral should be considered for excision.
Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days

101
Q

What should you do if you find a fissure that does not occur on the posterior midline?

A

Consider other underlying causes e.g. crohns disease

102
Q

When may haemorrhoids be painful?

A

If they’re external or if they are thrombosed

103
Q

Which haemorrhoids are prone to thrombosis?

A

External haemorrhoids
(Can be internal but much less common)

104
Q

What do thrombosed haemorrhoids look like and present with?

A

Present with significant pain
Purplish, oedematous, tender subcutaneous perianal mass

105
Q

How does a threadworm infestation present?

A

Asymptomatic in 90% of cases
Perianal itching, particularly at night
Girls may have vulval sympotms

106
Q

Whats the cause of a threadworm infestation?

A

Infestation occurs after swallowing eggs that are present in the environment.

107
Q

How is a threadworm infestation diagnosis made?

A

By applying sellotape to the perianal area and sending it to the lab for microscopy to see the eggs
However, most pt are treated empirically

108
Q

Whats the histological appearance of solitary rectal ulcers?

A

mucosal layer thickening with crypt distortion and lamina propria Fibromuscular obliteration

109
Q

What should you do if you find a lateral anal fissure?

A

Further investigation - if symptomatic then refer to colorectal surgeons via 2 WW pathway

Most fissures caused by constipation but 90% occur posteriorly and 10% anteriorly so anything else should raise concern

110
Q

What should you be concerned about if children present with anal fissures, reflex anal dilatation, enuresis, encopresis and recurrent UTIs?

A

Sexual abuse

111
Q

What is rectal intussusception?

A

Internal rectal prolapse

GI AND SURGERY (31 decks)

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