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Y4 final checklist_ SURGERY > Anorectal Disease > Flashcards

Anorectal Disease Flashcards

1
Q

What’s anal fissure?

Definition of acute and chronic anal fissure

A

Anal fissures are tears of the squamous lining of the distal anal canal.

  • if present for less than 6 weeks → ACUTE
  • if present for more than 6 weeks → CHRONIC
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2
Q

(3) risk factors for anal fissures

A
  • constipation
  • inflammatory bowel disease
  • sexually transmitted infections e.g. HIV, syphilis, herpes
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3
Q

Causes of anal fissure

A
  • trauma secondary to the passage of hard stool
  • associated with constipation
  • spasm of internal anal sphincter contributes to pain and → ischaemia + poor healing
  • Commoner in women

• Rarer causes:

  • Crohn’s
  • Herpes
  • Anal Ca
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4
Q

Presentation of anal fissure

A
  • Intense anal pain
  • Especially on defecation
  • May prevent pt. from passing stools
  • Fresh rectal bleeding
  • On paper mostly
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5
Q

Examination of anal fissure

A

PR often impossible due to pain

Inspection

• Midline ulcer is seen

  • Usually posterior @ 6 O’clock
  • May be anterior

• May be a mucosal tag – sentinel pile

-usually posterior @ 6 O’clock

• Groin LNs suggest complicating factor: e.g. HIV

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6
Q

Management of acute anal fissure

A

Management of an acute anal fissure (< 6 weeks)

  • dietary advice: high-fibre diet with high fluid intake
  • bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried
  • lubricants such as petroleum jelly may be tried before defecation
  • topical anaesthetics e.g. lignocaine
  • analgesia
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7
Q

Management of chronic anal fissure

A

Management of a chronic anal fissure (> 6 weeks)

  • the above techniques should be continued
  • topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure
  • if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery or botulinum toxin
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8
Q

What’s fistula in ano?

A

Abnormal connection between ano-rectal canal and

the skin

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9
Q

Pathophysiology of anal fistula

A
  • Blockage of intramuscular glands → abscess → abscess discharges to form a fistula
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10
Q

Conditions associated with anal fistula

A
  • Crohn’s
  • Diverticular disease
  • Rectal Ca
  • Immunosuppression
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11
Q

Classification of fistula in ano (2)

A
  • High: cross sphincter muscles above dentate line
  • Low: cross sphincter muscles below dentate line
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12
Q

What’s Goodshall’s role?

A

Goodsall’s Rule → determines path of fistula tract

  • Fistula anterior to anus track in a straight line (radial)
  • Fistula posterior to anus always have internal opening at the 6 o’clock position → curved track
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13
Q

Presentation of fistula in ano (2)

A
  • Persistent anal discharge
  • Perianal pain or discomfort
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14
Q

Findings on examination of fistula in ano

A
  • May visualise external opening: may be pus
  • Induration around the fistula on DRE
  • Proctosopy may reveal internal opening
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15
Q

Ix for fistula in ano (2)

A
  • MRI
  • Endoanal US
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16
Q

Management of:

  • low fistula
  • high fistula
A

Extent of fistula must first be delineated (visualised) by probing the fistula during examination under anaesthetic

Low Fistula

  • Fistulotomy and excision
  • Laid open to heal

High Fistula
• Fistulotomy could damage the anorectal ring
• Suture – a seton – passed through fistula and
gradually tightened over months
-Stimulates fibrosis of tract
-Scar tissue holds sphincter together

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17
Q
A
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18
Q

Upper 2/3 of the anal canal

  • what epithelium
  • sensation
  • what artery and vein
  • what lymph nodes
A

Upper 2/3 of canal

  • Lined by columnar epithelium
  • Insensate
  • Superior rectal artery and vein
  • Internal iliac nodes
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19
Q

Lower 1/3 of the anal canal

  • epithelium
  • sensation
  • artery and veins
  • lymph nodes
A

Lower 1/3 of canal

  • Lined by squamous epithelium
  • Sensate
  • Middle and inf. rectal arteries and veins
  • Superficial inguinal nodes
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20
Q

What are:

  • dentate line
  • white line
A
  • Dentate line = squamomucosal junction
  • White line = where anal canal becomes true skin
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21
Q

What are (3) anal sphincters?

A
  • Internal anal sphincter
  • External anal sphincter
  • Anorectal ring
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22
Q

Anal sphincters:

A. Internal:

  • role and control

B. External: structure and control

A

Internal

  • Thickening of rectal smooth muscle
  • Involuntary control

External

  • Three rings of skeletal muscle (Deep, superficial, subcutaneous)
  • Voluntary control
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23
Q

What’s perianal haematoma?

A
  • Subcutaneous bleeding from a burst venule → caused by straining or the passage of hard stool
  • Also called an external pile
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24
Q

Presentation of Perianal haematoma

A
  • Tender blue lump at the anal margin
  • Pain worsened by defecation or movement
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25
Q

Management of perianal haematoma (2)

A
  • Analgesia + spontaneous resolution
  • Evacuation under LA
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26
Q

Proctalgia fugax

  • common group of patients
  • what is this
  • associated with which condition
A

Group: Young, anxious men

Proctalgia fugax: Crampy anorectal pain, worse @ night

• Unrelated to defecation

Association: trigeminal neuralgia

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27
Q

Management of proctalgia fugax

A
  • Reassurance
  • GTN cream
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28
Q

Perianal warts

  • common group of patients
A

Perianal warts

homosexual men (men who have sex with men)

29
Q

Types (2) of perianal warts and what’s the difference + treatment?

A

Perianal warts

A. Condylomata accuminata
• HPV
• Rx: podophyllin paint, cryo, surgical excision

B. Condylomata lata
•Syphilis
• Rx: penicillin

30
Q

What are haemorrhoids?

A
  • Haemorrhoidal tissue → part of the normal anatomy; contributes to anal continence
  • They are mucosal vascular cushions
  • found in the left lateral, right posterior and right anterior portions of the anal canal (3 o’clock, 7’o’clock and 11 o’clock respectively)
  • Haemorrhoids are said to exist when they become enlarged, congested and symptomatic
31
Q

Clinical features of haemorrhoids

A
  • painless rectal bleeding is the most common symptom
  • pruritus
  • pain: usually not significant unless piles are thrombosed
  • soiling may occur with third or forth degree piles
32
Q

Pathophysiology of haemorrhoids

A
  • Gravity, straining → engorgement and enlargement of anal cushions
  • Hard stool disrupts connective tissue around

cushions

  • Cushions protrude and can be damaged by hard stool → bright red (capillary) bleeding.
33
Q

Two types of haemorrhoids and what’s the difference

A

External

  • originate below the dentate line
  • prone to thrombosis, may be painful

Internal

  • originate above the dentate line
  • do not generally cause pain
34
Q

Classification of haemorrhoids

A
35
Q

What contributes to the development of haemorrhoids (causes)

A

Constipation with prolonged straining

• Venous congestion may contribute

  • Pregnancy
  • Abdominal tumour
  • Portal HTN
36
Q

Examination of haemorrhoids

A
  • full abdo exam → palpating for masses
  • Inspect perianal area: masses, recent bleeding
  • DRE: can’t palpate piles unless thrombosed
  • Rigid sigmoidoscopy → to identify higher rectal
37
Q

Conservative and medical management of haemorrhoids

A

Conservative

  • ↑ fibre and fluid intake
  • Stop straining @ stool

Medical

  • Topical preparations
  • Anusol: hydrocortisone
  • Topical analgesics
  • Laxatives: lactulose, fybogel
38
Q

Interventional management for haemorrhoids (4) and its SEs

A

Interventional

A. Injection with sclerosant (5% phenol in Almond oil)

  • Injection above dentate line
  • SE: impotence, prostatitis

B. Banding → thrombosis and separation

-SE: bleeding, infection

C. Cryotherapy

-SE: watery discharge post-procedure

D. Infra-red coagulation

39
Q

Surgical intervention for haemorrhoids (1)

  • name
  • discharge prescription
  • SEs
A

Haemorrhoidectomy

  • Excision of piles + ligation of vascular pedicles
  • Discharge with laxatives post-op
  • SE: bleeding, stenosis
40
Q

Management of Acutely thrombosed external haemorrhoids

A

Acutely thrombosed external haemorrhoids

  • if patient presents within 72 hours then referral should be considered for excision
  • Otherwise patients can usually be managed with stool softeners, ice packs and analgesia (topical lignocaine jelly)
  • Symptoms usually settle within 10 days
41
Q

Presentation of acutely thrombosed external haemorrhoids

A
  • typically present with significant pain
  • examination reveals a purplish, oedematous, tender subcutaneous perianal mass
42
Q

Pathogenesis of Perianal sepsis/abscess

A
  • Anal gland blockage → infection ( e.g. E.coli) → abscess
  • May develop from skin infections
  • E.g. sebaceous gland or hair follicle
  • Staphs
43
Q

(3) conditions associated with the development of anal abscesses

A
  • Crohn’s
  • DM
  • Malignancy
44
Q

Classification and symptoms of anal abscess (4)

A
  • Perianal: 45%
  • discrete local red swelling close to the anal verge
  • Ischiorectal: ≤30%
  • systemic upset
  • Extremely painful on DRE
  • Interphincteric / intermuscular: >20%
  • Pelvirectal / supralevator: ~5%
  • Systemic upset
  • Bladder irritation
45
Q

Presentation of anal abscess

A
  • Throbbing perianal pain → worse on sitting
  • Occasionally a purulent anal discharge
46
Q

Examination of anal abscess

A
  • Perianal mass or cellulitic area
  • Fluctuant mass on PR
  • Septic signs: fever, tachycardia
47
Q

Management of anal abscess

A
  • antibiotics

Most cases require examination under anaesthesia with incision and drainage

  • Wound packed
  • Heals by secondary intention
  • Daily dressing for 7-10 days

* Look for an anal fistula which complicates ~30% of

abscesses

48
Q

What’s Pilonidal Sinus?

A
  • Pilonidal: latin → “nest of hair”
  • Sinus: blind ending tract, lined by epithelial or

granulation tissue, which opens onto an epithelial

surface

49
Q

Pathophysiology of Pilonidal sinus

A
  • Hair works its way beneath skin → foreign body reaction → formation of abscess
  • Usually occur in the natal cleft
50
Q

Risk factors for Pilonidal abscess

A
  • M>F=4:1
  • Geo: Mediterranean, Middle east, Asians
  • Often overweight with poor personal hygiene
  • Occupations with lots of sitting: e.g. truck drivers
51
Q

Presentation of pilonidal abscess

A
  • Persistent discharge of purulent or clear fluid
  • Recurrent pain
  • Abscesses
52
Q

Management of pilonidal abscess

A

Conservative

  • Hygiene advice
  • Shave / remove hair from affected area

Surgical

  • Incision and drainage of abscesses
  • Elective sinus excision
  • Methylene blue to outline tract
  • Recurrence in 4-15%
53
Q

Types of anal cancers

A
  • 80% SCCs

Other:

  • melanomas
  • adenocarcinomas
54
Q

Anal margin tumours

  • type
  • prognosis
A

Anal margin tumours

  • Well differentiated keratinising lesions
  • Commoner in men
  • Good prognosis
55
Q

Anal canal tumours

  • origin
  • type
  • prognosis
A

Anal canal tumours

  • Arise above dentate line
  • Poorly differentiated, non-keratinising
  • Commoner in women
  • Worse prognosis
56
Q

Spread of anal carcinoma (2)

A
  • Above dentate line → internal iliac nodes
  • Below dentate line → inguinal nodes
57
Q

Conditions associated with anal carcinoma

A
  • HPV (16, 18, 31, 33) is important factor
  • ↑ incidence in men who have sex with men
  • ↑ incidence if perianal warts
58
Q

Possible presentations of anal cancer

A
  • Perianal pain and bleeding
  • Pruritis ani
  • Faecal incontinence
  • 70% have sphincter involvement @

presentation

  • possible → rectovaginal fistula
59
Q

Clinical examination of anal cancer

A
  • Palpable lesion in only 25%
  • ± palpable inguinal nodes
60
Q

Investigations of anal cancer

A

↓• Hb (ACD)

  • Endoanal US
  • Rectal EUA + biopsy
  • CT / MRI: assess pelvic spread
61
Q

Management of anal cancer

A
  • Chemoradiotherapy: most ptatients
  • Surgery in:
  • Tumours that fail to respond to radiotherapy
  • GI obstruction
  • Small anal margin tumours w/o sphincter

involvement

62
Q

What’s rectal prolapse?

A

Protrusion of rectal tissue through the anal canal

63
Q

Classification of rectal prolapse (2)

A

Type 1: Mucosal prolapse

  • Partial prolapse of redundant mucosa
  • Common in children: esp with CF
  • Essentially large piles \ same Rx

Type 2: Full thickness prolapse

  • Commoner CF type 1
  • Usually elderly females with poor O&G Hx
64
Q

Presentation of rectal prolapse

A
  • Mass extrudes from rectum on defecation
  • may reduce spontaneously or require manual

reduction

-May become oedematous and ulcerated→ pain and bleeding

  • Faecal soiling
  • Associated with vaginal prolapse and urinary incontinence
65
Q

Clinical examination of rectal prolapse

A
  • visible prolapse: brought out on straining
  • ± excoriation and ulceration
  • ↓ sphincter tone on PR
  • Assoc. uterovaginal prolapse
66
Q

Investigations in rectal prolapse

A

Si•gmoidoscopy to exclude proximal lesions

  • Anal manometry
  • Endoanal US
  • MRI
67
Q

Management of partial rectal prolapse

A

Partial Prolapse

  • Phenol injection
  • Rubber band ligation
  • Surgery: Delorme’s Procedure
68
Q

Conservative management of complete rectal prolapse

A
  • Pelvic floor exercises
  • Stool softeners
69
Q

Surgery for complete rectal prolapse (2)

A

Surgery

  • Abdominal Approach: Rectopexy
  • Lap or open
  • Mobilised rectum fixed to sacrum with mesh
  • Perineal Approach: Delorme’s Procedure
  • Resect mucosa and suture the two

mucosal boundaries

Y4 final checklist_ SURGERY (25 decks)

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