Anorectal disorders Flashcards
Which muscle is responsible for being able to squeeze on a finger during a PR exam?
external sphincter
Anus epithelium type
stratified squamous epithelium
Rectum epithelium type
columnar epithelium
What does the dentate line indicate?
junction of hindgut and proctodenum
Venous drainage above dentate line
superior rectal vein + portal vein (portal circulation)
Venous drainage below dentate line
IVC (systemic circulation)
What are haemorrhoids?
varicose veins of anal canal
Haemorrhoids symptoms
bleeding
prolapse
irritation
pain - less common
Describe the grading of haemorrhoids
grade 1 = no prolapse
grade 2 = prolapse but reduce spontaneously
grade 3 = prolapse, stay reduced if pushed back manually
grade 4 = irreducible (intero-external haemorrhoid)
Haemorrhoids differential diagnosis
anal fissure
anorectal polyps
mucosal prolapse
bleeding from higher source - usually mixed with faeces
anorectal carcinomas
What investigation would you perform on a 45yM who has red rectal bleeding and itching, no altered bowel habit and no FH?
flexible sigmoidoscopy
How far can a flexible sigmoidoscopy view?
up to splenic flexure
Haemorrhoids management options
conservative (reassurance, diet)
injection or rubber band ligation
surgical - HALO, haemorrhoidectomy, stapled haemorrhoidopexy
Complications of haemorrhoid surgery
pain
haemorrhage
infection
stenosis
incontinence
recurrence
impacted faeces
retention of urine
What is an anal fissure?
tear causing a painful linear ulcer at the margin of the anus
Anal fissure symptoms
pain during and after bowel motion
bleeding
itching
What conditions should you think of if someone has a lateral anal fissure?
Crohn’s
lymphoma
leukaemia
anal cancer
syphilis/STD
trauma
TB
Most common location of anal fissure
posterior midline
How is an anal fissure diagnosed?
physical examination is diagnostic
sentinel skin tag (externally), fissure, hypertrophied papilla (internally)
What is a sentinel pile?
oedematous skin tag at the lower end of chronic anal fissure
A patient presents to clinic with posterior anal fissure, what is the most commonly used treatment?
diltiazem cream
Chronic anal fissure treatment
ointments - nitro-glycerine ointment, diltiazem ointment
botulinum toxin A injection
surgery - lateral internal sphincterotomy
Perianal abscess symptoms
pain - increased on walking and straining
fever
malaise
inflammation signs - calor, rubor, dolor, tumour, function laesse
Name some locations of anal abscessed
perianal
ischiorectal
supralevator, intersphincteric, submucous
ischiorectal post-anal space
Abscesses treatment
surgical drainage - cruciate incision, sometimes a drain may be left
What is an anal fistula?
abnormal communication between the interior of the anal canal or rectum and the skin surface
(rarer forms may communicate with the vagina, large bowel and bladder)
What is the difference between a fistula and a sinus?
A fistula is an abnormal pathological pathway between two anatomic spaces or a pathway that leads from an internal cavity or organ to the surface of the body. A sinus tract is an abnormal channel that originates or ends in one opening
Anal fistula symptoms
discharge
pain and swelling when fistulas become blocked and abscesses recur
irritation causes itching and discomfort
Describe Goodsall’s rule for anal fistulas
if perianal skin opening is posterior to the transverse anal line, the fistulous tract will open into the anal canal in the midline posteriorly, sometimes taking a curvilinear course
a perianal skin opening anterior to the transverse anal line is usually associated with a radial fistulous tract
helps locate site of internal opening
Fistula treatment
seton
fistulotomy
fibrin glue
fistula plugs
LIFT procedure
advancement flap
Why is there reluctance in performing fistulotomy for fistula in ano despite high success rate?
risk of incontinence
What is a pilonidal sinus?
a small hole or ‘tunnel’ in the skin. It usually develops in the area where the buttocks divide
Pruritis ani symptoms and signs
itching
burning
irritation
worse at night
reddened, oedematous, ulcerations and excoriations
skin atrophic or hypertrophic with associated nodularity and scarring
What causes anal warts?
HPV
