Anorectal disease Flashcards
Causes of perianal pain
- Anal fissure
- Hemorrhoids
- Colitis
- Perineal abscess
- Anorectal carcinoma
Classification of hemorrhoids
Class 1: Seen on examination
Class 2: Prolapse but reduce spontaneously
Class 3: Manual reduction required
Class 4: Not reducible
Conservative Management anal fissure
- High-fibre diet
- Adequate fluid intake
- Sitz baths
- Topical analgesia
- Glycerin trinitrate intra-anal
- Stool softeners/osmotic/stimulant: docusate sodium, polyethylene glycol, bisacodyl
Management of hemorrhoids
High fibre diet, stool softeners Fluids Sitz bath Avoidance of straining Band ligation, infrared coagulation Hemorrhoidectomy
Important differential with non-healing anal fissue or fissure located other than posterior area of anus
Crohn Malignancy
Etiology and definition of anal fissure
- Longitudinal ulcer in skin lined anal canal
- Etiology- most commonly associated with passage/trauma when passing hard stool
Symptoms of anal fissure
- pain during and after defecation Internal spincter spasm= ++pain
- PR bleeding
- Pruritis
- Constipation
- Discharge
Diagnosis of anal fissure
History
Clinical examination
–>most common posteriorly, if anterior consider underlying condition
Tear
Sentinel skin tag
Surgical management of anal fissure
- Internal lateral sphincterotomy->incision of internal sphincter, not past dendate line
- Fluids, fibre, bulking agents
- After procedure may have key hole defect->incision may not heal properly leading to passive soiling
Mechanism of chronic anal fissure
Fissure->pain->+sphincter tone->ischemia->fissure
Will see anal papilla, exposed fibres of sphincter and anal skin tag
Classification of anorectal abscess
Perianal most common, fistula in ano posterior
Ischiorectal, transphincteric
Intersphincteric
Supralevator, suprasphicteric
Extrasphincteric
Etiology of abscess
Blocked anal gland->infected
Risks for perianal abscess
DM Immunocompromised Chrohs
Clinical features of perianal abscess
Throbbing, swollen, erythematous, discharge, fever
Management of perianal abscess
- Analgesia
- Start fluids->keep NBM, surgical consult
- Surgical drain
- Have warm baths/clean 2-3 day
- Consider antibiotics if polymicrobial, immunocompromised, DM, elderly ->Gentamicin, ampicillin + metronidazole
- Fluids, fibre, avoid hard stools
Risk factors for anorectal abscess and differential
- Fistula
- Chron’s
- Male
Differential
- Chrohns
- Infected sebaceous gland
- Hydradenitis suppurativa
Etiology of fistula in ano
Idiopathic Infection Crohns TB Cancer Iatrogenic Trauma Foreign body Radiation
Symptoms in fistula
Recurrent abscess Discharge Pain/discomfort
Diagnosis and investigations in fistula
- Examination->may find end tract on PR.
- Should determine level of internal opening in relation to levator mechanism
–>Anterior ex open- drain into anus at dendate line
–>Posterior take curved to enter anal canal in midline
- Investigations:
Sigmoidoscopy to rule out inflammatory bowel examine under anaesthesia
Fistulogram
Endoluminal US
MRI useful in complex
Management of high and low fistula
- Low(does not cross many spinchter muscles)->lay tract open with fistulotomy: can heal via secondary intention
- High (does cross sphincter muscles)->requires
a. seton procedure, or else with have flow incontinence, allows drainage of fistula + healing
b. Advancement flap->repair of internal gland with suture, then advancing skin to cover fistula
Clinical features in anal cancer
Pain
Pruritis
Bleeding
Moisture
Most commonly epidermoid type (SCC and variants)
Risk factors for anal cancer
Homosexual males
HPV
Anal sex
Syphillis/LGV HIV
Tobacco