Anorectal disease Flashcards
How does rectal prolapse occur?
Weak anal sphincter
Prolonged straining/ chronic neuro disorder
Mucosa (T1) or all layers (T2) of rectum protrude through anus
What are the risk factors for rectal prolapse?
Elderly
Multiparous females
↑IA pressure (Constipation, diarrhoea, BPH, pregnancy, chronic cough, CF)
Pelvic floor dysfunction
Parasitic infection
Neuro disease (caudal equine, lumbar disc disease)
What is the clinical presentation of rectal prolapse?
Mass protruding through anus Pain Constipation Faecal incontinence, discharge Ulceration
How is a rectal prolapse investigated?
DRE
Barium enema/Colonoscopy
Stool MC&S
Sweat test
What are the levels the rectum can prolapse?
INITIAL: After bowel movement + retracts spontaneously
NEXT: Protrudes often w/straining + valsalva manoeuvres
LATE: Protrudes w/normal ADL, manually replaced
How is rectal prolapse managed?
Conservative:
KIDS: Water-soluble lubricants, ↑fibre, mild laxative
OLD: Manual reduction- cover w/sugar, submit circumanal ring
Surgery: Rectosigmoidectomy = STRANGULATED, haemorrhoidectomy, retropexy
How do haemorrhoids occur?
Straining & effects of gravity & ↑anal tone
Disrupts & dilates anal cushions (spongy vascular tissue) contribute to anal closure
Attached by smooth muscle & elastic tissue but prone to displacement
Leads to piles
Vulnerable to trauma & bleed easily
What are the risk factors for haemorrhoids?
Constipation
Congestion (pelvic Ca, portal HTN, pregnancy)
How are internal haemorrhoids graded?
1st = Remains in rectum 2nd = Prolapse through anus on defecation, spont resolve 3rd = Require digital reduction 4th = Persistently prolapsed, cannot be reduced
How can you tell if haemorrhoids are internal or external?
E: Below dentate line- prone to thrombosis
I: Above dentate line
How do haemorrhoids present?
Painless rectal bleeding- BRIGHT red
Pruritus ani (irritation)
Mucous discharge
Rectal fullness/discomfort
How are haemorrhoids investigated?
1) PR exam: Palpable external, internal NOT palpable
2) Proctoscopy: Internal haemorrhoids
3) Sigmoidoscopy: Look for high rectal pathology
How are haemorrhoids managed?
1st degree- MEDICAL: ↑fluids, ↑fibre, good hygiene, topical analgesia + steroids, AVOID codeine & NSAIDs, stool softener
2nd-3rd degree- NON-OPERATIVE: Rubber band ligation, Sclerotherapy, cryotherapy
Surgery: Excision or stapled
What are the causes of an anorectal abscess?
E.Coli
Staph
STI
Blocked anal gland
What are the risk factors for an anorectal abscess?
DM ImmunoS Anal sex Crohn's Diverticulitis
Where can anorectal abscesses occur?
Peri-anal- MOST COMMON (direct extension of sepsis in intersphincteric plan by perianal skin)
Ischiorectal
Intersphincteric
How does an anorectal abscess present?
Pain- throbbing, worse on sitting Hardened tissue in peri-anal area Erythematous, swollen, tender Lump/nodule at anus Discharge from rectum Fever Constipation
How is an anorectal abscess investigated?
1) DRE
2) Procto-sigmoidoscopy
How is an anorectal abscess managed?
1) Incision & drainage
2) Analgesia
3) Abx
What is a complication of an anorectal abscess?
Fistula-in-ano = 40%
How does an anal fissure occur?
Painful tear in squamous mucosa of lower anal canal
What causes an anal fissure?
Constipation Hard faeces Spasms (constricts rectal artery leads to ischaemia & poor healing) Syphilis Herpes Trauma Crohn's Cancer
How does an anal fissure present?
Anal pain: worse on defecation, persists post-defecation
Fresh bright red blood
How is an anal fissure managed?
1) Bulk forming laxative
1) TOP anaesthetic- Lidocaine 5% ointment
2) TOP Diltiazem/Botox injection
3) Analgesia (NSAID, paracetamol)
