Anorectal disease Flashcards

1
Q

How does rectal prolapse occur?

A

Weak anal sphincter
Prolonged straining/ chronic neuro disorder
Mucosa (T1) or all layers (T2) of rectum protrude through anus

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2
Q

What are the risk factors for rectal prolapse?

A

Elderly
Multiparous females
↑IA pressure (Constipation, diarrhoea, BPH, pregnancy, chronic cough, CF)
Pelvic floor dysfunction
Parasitic infection
Neuro disease (caudal equine, lumbar disc disease)

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3
Q

What is the clinical presentation of rectal prolapse?

A
Mass protruding through anus
Pain
Constipation
Faecal incontinence, discharge
Ulceration
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4
Q

How is a rectal prolapse investigated?

A

DRE
Barium enema/Colonoscopy
Stool MC&S
Sweat test

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5
Q

What are the levels the rectum can prolapse?

A

INITIAL: After bowel movement + retracts spontaneously
NEXT: Protrudes often w/straining + valsalva manoeuvres
LATE: Protrudes w/normal ADL, manually replaced

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6
Q

How is rectal prolapse managed?

A

Conservative:
KIDS: Water-soluble lubricants, ↑fibre, mild laxative
OLD: Manual reduction- cover w/sugar, submit circumanal ring
Surgery: Rectosigmoidectomy = STRANGULATED, haemorrhoidectomy, retropexy

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7
Q

How do haemorrhoids occur?

A

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

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8
Q

What are the risk factors for haemorrhoids?

A

Constipation

Congestion (pelvic Ca, portal HTN, pregnancy)

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9
Q

How are internal haemorrhoids graded?

A
1st = Remains in rectum
2nd = Prolapse through anus on defecation, spont resolve
3rd = Require digital reduction
4th = Persistently prolapsed, cannot be reduced
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10
Q

How can you tell if haemorrhoids are internal or external?

A

E: Below dentate line- prone to thrombosis
I: Above dentate line

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11
Q

How do haemorrhoids present?

A

Painless rectal bleeding- BRIGHT red
Pruritus ani (irritation)
Mucous discharge
Rectal fullness/discomfort

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12
Q

How are haemorrhoids investigated?

A

1) PR exam: Palpable external, internal NOT palpable
2) Proctoscopy: Internal haemorrhoids
3) Sigmoidoscopy: Look for high rectal pathology

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13
Q

How are haemorrhoids managed?

A

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

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14
Q

What are the causes of an anorectal abscess?

A

E.Coli
Staph
STI
Blocked anal gland

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15
Q

What are the risk factors for an anorectal abscess?

A
DM
ImmunoS
Anal sex
Crohn's
Diverticulitis
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16
Q

Where can anorectal abscesses occur?

A

Peri-anal- MOST COMMON (direct extension of sepsis in intersphincteric plan by perianal skin)
Ischiorectal
Intersphincteric

17
Q

How does an anorectal abscess present?

A
Pain- throbbing, worse on sitting
Hardened tissue in peri-anal area
Erythematous, swollen, tender 
Lump/nodule at anus
Discharge from rectum
Fever
Constipation
18
Q

How is an anorectal abscess investigated?

A

1) DRE

2) Procto-sigmoidoscopy

19
Q

How is an anorectal abscess managed?

A

1) Incision & drainage
2) Analgesia
3) Abx

20
Q

What is a complication of an anorectal abscess?

A

Fistula-in-ano = 40%

21
Q

How does an anal fissure occur?

A

Painful tear in squamous mucosa of lower anal canal

22
Q

What causes an anal fissure?

A
Constipation
Hard faeces
Spasms (constricts rectal artery leads to ischaemia & poor healing)
Syphilis
Herpes
Trauma
Crohn's
Cancer
23
Q

How does an anal fissure present?

A

Anal pain: worse on defecation, persists post-defecation

Fresh bright red blood

24
Q

How is an anal fissure managed?

A

1) Bulk forming laxative
1) TOP anaesthetic- Lidocaine 5% ointment
2) TOP Diltiazem/Botox injection
3) Analgesia (NSAID, paracetamol)

25
Q

What is a fistula-in-ano?

A

Blockage of intramuscular gland ducts
Leads to abscess which discharges & forms fistula
Communication between skin & anal canal/rectum

26
Q

What can cause a fistula-in-ano?

A
Perianal abscess!
Sepsis
Crohn's
TB
Diverticular disease
Rectal Carcinoma
27
Q

How are anal fistulas categorised?

A

Intersphincteric
Transsphincteric
Suprasphincteric
Extrasphincteric

28
Q

How is an anal fistula investigated?

A

MRI

Endoanal USS

29
Q

How is a fistula-in-ano managed?

A

Surgical drainage of abscess
Fistulotomy & excision
High fistula = Seton sutures
Low = open to heal by secondary intention

30
Q

What are the common paths of a fistula-in-ano?

A

Goodsall’s rule – determines path of fistula track
Anterior– track is straight (radial)
Posterior– internal opening is lateral/curved

31
Q

Where can anal cancer occur?

A

3 regions:

1) Perianal skin
2) Anal canal
3) Lower rectum

32
Q

What are the causes of anal cancer?

A

HPV- common in MSM & ImmunoS

Crohn’s: Low chance but higher than public

33
Q

Where does anal cancer usually metastasise to?

A

Lungs

Liver

34
Q

How does anal cancer present?

A

Mass
Bleeding
Pain
Rare: Inguinal node mass, Sx of mets

35
Q

How is anal cancer investigated?

A

Anoscopy: Visualise
Biopsy
CT

36
Q

How is anal cancer managed?

A

RT + Fluorouracil + Mitomycin