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General surgery > Anorectal disease > Flashcards

Anorectal disease Flashcards

1
Q

Anal fissue : Definition

A

An anal fissure is a tear in the mucosal lining of the anal canal, most commonly due to trauma from defecation of hard stool. It can be classified according to its duration:

  • Acute – present for <6 weeks
  • Chronic – present for >6 weeks
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2
Q

Anal fissure : Risk factors

A

Anal fissures are usually caused by inflammation or trauma to the anal canal. The major risk factors include:

  • Constipation
  • Dehydration
  • Inflammatory bowel disease
  • Chronic diarrhoea
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3
Q

Anal fissure : Clinical presentation

A

intense pain post-defecation
Bleeding (bright, red) and itching post-defecation

Examination : visible or present during palpation in DRE

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4
Q

Anal fissure : Medical management

A
  1. Lifestyle : increase fluid, fibre, softening laxative (movicol/lactulose)
    * Short term : topical lidocaine
  2. Second line - if still stymptomatic
    * GTN / Diltiazem cream - increases blood supply to the region and relaxes anal sphincter - reduce pressure and pain
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5
Q

Anal fissure : Surgical management

A

Third line : when medical management has failed to resolve the symptoms after at least 8 weeks.

  1. Botox injections
    the internal anal sphincter, to relax the sphincter and promote healing of the fissure.
  2. Lateral sphincterotomy
    can be performed, involving division of the internal anal sphincter muscle.
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6
Q

Perinanal fistula : Definition

A

A perianal fistula (fistula-in-ano) refers to an abnormal connection between the anal canal and the perianal skin.
* majority are associated with anorectal abscess formation

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7
Q

Perinanal fistula : Pathophysiology

A

Perianal fistulas arise from infections in the anal glands
1 . Abscess in anal gland -
* Inflammation of surrounding tissue - damage tissue integrity
* increases pressure within surrounding tissues

2 . Rupture of abscess
* Released pus follow path of least resistance
* Creates tunnel/fistula that connects the anal gland to skin around the anus or other structures

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8
Q

Perinanal fistula : Risk factors

A
  1. Inflammatory bowel disease, mainly perianal Crohn’s Disease
    -Persistent inflammation weakens tissue integrity, increasing risk of fistulas forming
  2. Systemic diseases, typically Diabetes Mellitus : increases risk of abscess formation
  3. History of trauma to the anal region
  4. Previous radiation therapy to the anal region
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9
Q

Perinanal fistula : Investigations

A
  1. MRI imaging
    * used to visualise the anatomy of the tract
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10
Q

Perinanal fistula : Management

A

Surgical intervention
* Superficial disease : Fistulotomy
Laying the tract open by cutting through skin and subcutaneous tissue
* High tract disease : Placement of seton through fistula

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11
Q

Anorectal abscess : Definititon

A

An anorectal abscess refers to a collection of pus in the anal or rectal region.
* One third of patients with an anorectal abscess have an associated perianal fistula at the time of presentation.
* They are more common in men than in women and have high rates of recurrence.

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12
Q

Anorectal abscess : Pathophysiology

A
  1. Anal glands : secrete mucous fluid into the anal canal via the anal canal
    to facilitate the passage of stool
  2. Blockage of anal duct
    Fluid which will lead to infection of the anal glands
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13
Q

Anal abscess : location

A

Anal glands are located in the intersphincteric space (between the internal and external anal sphincters)
Infection can spread to;
(1) Perianal
(2) Ischiorectal
(3) Intersphincteric
(4) Supralevator

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14
Q

Anal abscess : Clinical presentation

A
  1. Severe pain in the perianal region, worse with direct pressure (i.e. when sat down)
  2. Discharge or bleeding from perianal space
  3. Eythematous, fluctuant, tender perianal mass

Severe abscesses may present with systemic features *such as fever or rigors, general malaise, or clinical features of sepsis

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15
Q

Anal abscess : Investigations

A
  1. Clinical diagnosis
    * Anal abscess without fistula/rectal pathology : Ix for underlying diabetes mellitus
  2. MRI pelvis : if complex perinal fistula or Perianal Crohns disease
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16
Q

Anal abscess : Management

A
  1. Examine under anaesthesia
  2. Incision and drainage of abscess
  3. Intraoperative proctoscopy : check of presence of fistula
17
Q

Anal canal : Physiology

A

Internal mucous membrane of the anus
* Divided by Pectinate line into two portions

  1. Above Pectinate line : columnar epithelium, lacks pain receptors
  2. Below Pectinate line : non keratinised squamous epithelium has no ducts
    * Sensitive to pain
18
Q

Haemorrhoids : Pathophysiology

A

Anal valvular cushions : collection of venous/arterial plexus, highly vascular

Haemorrhoids are defined as an abnormal swelling or enlargement of the anal vascular cushions.

Haemorrhoid may occur due to ;
1. Chronic increased intra abdominal pressure - causes swelling of vasculture
2. Increase in venous pressure - 2nd to portal hypertension

Hemorrhoids can be either;
inside your anus (internal)
or
under the skin around your anus (external).

19
Q

Haemorrhoids : Risk factors

A

excessive straining (from chronic constipation), increasing age, and raised intra-abdominal pressure (such as pregnancy, chronic cough, or ascites).

Other less common risk factors include pelvic or abdominal masses, family history, cardiac failure, or portal hypertension.

20
Q

Internal haemorrhoids : Physiology

A
  • Upper anal canal : Internal haemorrhoid site
  • Above dentate line : no sensation

3x vascular anal cushions

Supply : contain venous plexus from the retinal artery and vein - superior haemorroidal plexus

Location : right anterior at 11 o’clock, right posterior at 7 o’clock and left lateral aspect at 3 o’clock

Continence : contribute to closure pressure at rest or when there is increase in abdominal pressure
-Blood drains away during defectation, allowing anal pressure to relax

21
Q

Internal haemorrhoids : Classification

A

When these cushions become abnormally enlarged, they can cause symptoms and become pathological, termed haemorrhoids.
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

22
Q

External haemorrhoids

A
  • Below the dentate (or pectinate) line.
  • covered proximally by anoderm and distally by skin, both of which are sensitive to pain and temperature } sensoru supply by pudendal nerve

Supply : Inferior haemorrhoidal plexus
, external hemorrhoids are drained via the inferior rectal vein into the inferior vena cava.

Location;
occur circumferentially under the anoderm and can occur in any location.

Finally, external hemorrhoids are drained via the inferior rectal vein into the inferior vena cava.

23
Q

Haemorrhoids : Clinical presentation

A

Internal haemorrhoids
1. Painless bright red rectal bleeding
* Commonly after defecation
2. Itching, pruritus - due to chronic mucus discharge
3. Assoc changes in bowel movements

External haemorrhoids
1. Pain
2. Rectal lump, fullness
3. A thrombosed prolapsed haemorrhoid will present as a purple/blue, oedematous, tense, and tender perianal mas

24
Q

Haemorrhoids : Investigation

A
  1. Prostoscopy : confirm diagnosis
  2. Colonoscopy : exclude any concurrent anorectal pathology
25
Q

Haemorrhoids : Conservative management

A
  1. Life style advice : increase fibre/fluid intake, topical lidocaine
  2. 1st and 2nd degree haemorrhoids
    * Rubber band ligation
26
Q

Haemorrhoids : Surgical management

A
  1. 2nd and 3rd degree Haemorrhoids : Haemorrhoidal artery ligation
  2. 3rd degree and 4th degree Haemorrhoids : Haemorrhoidectomy

The main complications following surgical interventions for haemorrhoids include recurrence, anal stricturing, or faecal incontinence.

27
Q

Pilonidal sinus disease : Defintion

A

characterised by the formation of a sinus in the cleft of the buttocks.

It most commonly affects males aged 16-30 years.

28
Q

Pilonidal sinus disease : Pathophysiology

A
  1. Infected hair follicle in the intergluteal cleft
  2. This inflammation obstructs the opening of the follicle, which extends inwards, forming a ‘pit’
  3. Inflammatory reaction may then lead to formation of a cavity, connected to the surface of the skin by an epithelialised sinus tract
  4. These fluid-filled cavities (cysts) will often discharge serous fluid and can periodically become acutely infected to form a pilonidal abscess.
29
Q

Pilonidal sinus disease : Risk factors

A

Men 16-40 years
* Excessive sitting, obesity and coarse dark hair

30
Q

Pilonidal sinus disease : Clinical features

A
  1. Sinus at the cleft of buttocks - discharging fluid
  2. Infection of sinus - pilonidal abscess
    * swelling, erithematous region of the cleft of the butccoks
    * Fluctuant, tender mass
31
Q

Pilonidal sinus disease : Ix

A
  1. Proctoscopy / MRI to r/o other sinus disease
32
Q

Pilonidal sinus disease - Mx

A
  1. Pilonidal disease : removal of hair and ensure area is clean
  2. Pilonidal abscess : Incision and drainage
33
Q

Rectal prolapse : defintion

A

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

34
Q

Rectal prolapse : Types

A

Partial thickness – the rectal mucosa protrudes out of the anus
* are associated with the loosening and stretching of the connective tissue that attaches the rectal mucosa to the remainder of the rectal wall
* often occurs in conjunction with long standing haemorrhoidal disease.

Full thickness – the rectal wall protrudes out the anus
* may be caused by chronic straining secondary to constipation, a chronic cough, or from multiple vaginal deliveries.
* full prolapse suggest that is a form of sliding hernia, through a defect of the fascia of the pelvic region

35
Q

Rectal prolapse : Clinical features

A
  1. Rectal mucus discharge
  2. Rectal bleeding
  3. faecal incontinence

4 . Full thickness prolapses - begin internally *
* sensation of *rectal fullness, tenesmus, or repeated defecation.

5 . On examination
the prolapse may not always be evident
weakened anal sphincter is identified.

36
Q
A

suspected internal prolapse
defecating proctography and examination under anaesthesia

37
Q

Rectal prolapse : Management

A

Conservative Mx : increasing dietary fibre and fluid intake
Surgical repair - definitive management

General surgery (3 decks)

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