Anorectal disease Flashcards
What are haemorrhoids or piles?
Dilated haemorrhoidal veins located within submucosal layer of lower rectum.
Types of haemorrhoids and the difference?
External haemorrhoids
- distal to the dentate line (a line which divides the upper two-thirds and lower third of the anal canal)
Internal haemorrhoids
- proximal to dentate line
Complication of haemorrhoids?
Thrombosis -risk of clot formation within the haemorrhoids and can be very painful.
Causes of haemorrhoids/piles?
Ageing
Low fibre diet
Congenital weakness of venous walls
Increase intra-abdominal pressure
- constipation
- heavy lifting
- abdominal exercises
- pregnancy, childbirth
- ascites
- pelvic mass
- chronic cough
How is haemorrhoids or piles diagnosed?
Clinical exam -inspection of the anal verge and perianal area & DRE
Anoscopy -plastic device is inserted into the anus and visualise internal haemorrhoids; done if external area is normal
Colonoscopy -this is done if physical exam and anoscopy is negative,
How do haemorrhoids present?
- rectal bleeding -bright red, found on toilet paper or on stool
- perianal pruritus (itching)
- sensation of fullness in perianal area
- significant acute perianal pain (if thrombosed)
- haemorrhoids present
- +/- bleeding
- firm, painful, inflamed perianal mass if thrombosed
Treatment and management of haemorrhoids?
Hospital admission
- if acute pain, thrombosed external haemorrhoids, and present within 72 hrs of pain onset.
Encourage fluid intake
Increase dietary fibre
Topical tx:
- ointment = external haemorrhoids
- suppository (soft gel pill that is inserted into the rectum, which dissolves and releases the medication inside) = internal haemorrhoids
Refer if no improvement.
- Other tx includes:
- banding
- sclerotherapy
- photocoagulation
- haemorrhioidectomy
What is anal fissure?
Tear or ulcer in the lining of the anal canal.
Anal fissure can be classified into?
acute <6 wks
chronic >6 wks
Complications of anal fissure?
- anorectal fistula (abnormal passageway that develops from inside the anus to the skin outside)
- infection and/or abscess
- faecal impaction (stool building up inside the rectum)
Causes of anal fissures?
Primary anal fissues
- due to trauma from passing hard or loose stools
Secondary anal fissures
- IBD
- STIs (HIV, HSV, syphilis)
- colorectal cancer
- psoriasis
- skin infections (bacteria, fungi, viral)
- anal trauma (anal surgery or anal sex)
- pregnancy, childbirth
How does anal fissure present?
-anal pain when passing stool -severe, sharp, deep burning pain lasting several hours
- tearing sensation on passing stool
- bright red stool or on toilet paper
- fissure visible on anal exam
- sentinel pile (skin tag associated with fissure)
How is anal fissure diagnosed?
Clinical diagnosis from physical examination.
Acute anal fissures
- superficial with well distinguished edges
Chronic anal fissures
- wider and deep with muscle fibres visible in the base
- edges often swollen
- +/- skin tag
Primary anal fissures
- singular fissure
- posterior midline of anus
Secondary anal fissures
- multiple anal fissure
- irregular outline
- location may be lateral of anus
How are anal fissures treated?
Encourage fluid intake.
Increase dietary fibre.
Keep anal area dry and clean (prevent infection).
Paracetamol or Ibuprofen for pain relief.
Sit in shallow, warm bath several times daily.
Topical anaesthetic (lidocaine) for extreme pain before passing stool.
Rectal GTN →if primary fissure and symptoms persist >1wk
Refer to colorectal surgery →if unhealed after 6-8wks
What is anorectal abscess?
Infection of soft tissues around the anus or rectum.
This can be perianal abscess or perirectal abscess.
Risk factors for anorectal abscess?
- immunodeficiency
- diabetes
- receptive anal intercourse
- Crohn’s disease
Diagnosis of anorectal abscess?
Clinical diagnosis from physical examination
- DRE
- USS, MRI
- Culture and sensitivity of discharge
Presentation of anorectal abscess?
- perianal pain
- perianal swelling
- discharge
- rectal bleeding
- fever
- malaise
- tachycardia
- perianal tenderness, erythema, warmth, swelling, fluctuance
- perianal/rectal induration
- purulent discharge
Treatment of anorectal abscess?
Drainage of abscess
- perianal →outpatient incision and drainage
- perirectal →surgical discharge
Sitz baths following drainage
- helps with healing and removing any last bits of the abscess
Prescribe broad spectrum abx in high-risk pts (e.g. DM, immunocompromised, elderly, significant associated cellulitis)
- Abx must cover anaerobes, gram negative bacteria
- E.g. ampicillin/sulbactam or cefoxitin AND metronidazole, ciprofloxacin or clindamycin.
Refer to specialist if tx fails.
What is anorectal fistula?
Abnormal connection between two hollow spaces -rectum and skin near anus.
How is anorectal fistula caused?
Anorectal abscess
How is anorectal fistula diagnosed and managed?
Clinical diagnosis
CT or MRI if diagnosis is uncertain
Tx: Fistulotomy
How does anorectal fistula present?
- perianal pain
- perianal swelling, erythema, irritation, pruritus
- purulent discharge
- rectal bleeding
- bowel incontinence
- fistula opening
- induration of fistula tract
What is pilonidal disease?
An acquired disease where hair follicles become inverted into skin, forming a chronic cysts and a sinus tract that goes from the inverted hair follicle towards out of the skin.
Where does pilonidal disease occur?
Natal cleft of sacrococcygeal area.
Presentation of pilonidal disease and how is it diagnosed?
Clinical diagnosis
Asymptomatic
- might complain of one or more non-tender lumps in natal cleft
- +/- emergent hair from the lump area
Symptomatic
- acute abscess
- painful, fluctuant lump in natal cleft
- +/- purulent discharge, erythema, fever
- discharging sinus
- chronic pain
- chronic intermittent discharge or bleeding
- recurrent abscess formation
How is pilonidal disease managed?
Asymptomatic tx:
- local hygiene with regular baths/showers
Symptomatic tx for acute abscess:
- same day I&D (incision and drainage)
- if small →can be removed in primary care
- if big →refer for surgical
- abx if associated cellulitis
Symptomatic tx for discharing sinus:
- surgical correction
