Anorectal disorders

Question 1

Which muscle is responsible for being able to squeeze on a finger during a PR exam?

Answer 1

external sphincter

Question 2

Anus epithelium type

Answer 2

stratified squamous epithelium

Question 3

Rectum epithelium type

Answer 3

columnar epithelium

Question 4

What does the dentate line indicate?

Answer 4

junction of hindgut and proctodenum

Question 5

Venous drainage above dentate line

Answer 5

superior rectal vein + portal vein (portal circulation)

Question 6

Venous drainage below dentate line

Answer 6

IVC (systemic circulation)

Question 7

What are haemorrhoids?

Answer 7

varicose veins of anal canal

Question 8

Haemorrhoids symptoms

Answer 8

bleeding
prolapse
irritation
pain - less common

Question 9

Describe the grading of haemorrhoids

Answer 9

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)

Question 10

Haemorrhoids differential diagnosis

Answer 10

anal fissure
anorectal polyps
mucosal prolapse
bleeding from higher source - usually mixed with faeces
anorectal carcinomas

Question 11

What investigation would you perform on a 45yM who has red rectal bleeding and itching, no altered bowel habit and no FH?

Answer 11

flexible sigmoidoscopy

Question 12

How far can a flexible sigmoidoscopy view?

Answer 12

up to splenic flexure

Question 13

Haemorrhoids management options

Answer 13

conservative (reassurance, diet)
injection or rubber band ligation
surgical - HALO, haemorrhoidectomy, stapled haemorrhoidopexy

Question 14

Complications of haemorrhoid surgery

Answer 14

pain
haemorrhage
infection
stenosis
incontinence
recurrence
impacted faeces
retention of urine

Question 15

What is an anal fissure?

Answer 15

tear causing a painful linear ulcer at the margin of the anus

Question 16

Anal fissure symptoms

Answer 16

pain during and after bowel motion
bleeding
itching

Question 17

What conditions should you think of if someone has a lateral anal fissure?

Answer 17

Crohn’s
lymphoma
leukaemia
anal cancer
syphilis/STD
trauma
TB

Question 18

Most common location of anal fissure

Answer 18

posterior midline

Question 19

How is an anal fissure diagnosed?

Answer 19

physical examination is diagnostic

sentinel skin tag (externally), fissure, hypertrophied papilla (internally)

Question 20

What is a sentinel pile?

Answer 20

oedematous skin tag at the lower end of chronic anal fissure

Question 21

A patient presents to clinic with posterior anal fissure, what is the most commonly used treatment?

Answer 21

diltiazem cream

Question 22

Chronic anal fissure treatment

Answer 22

ointments - nitro-glycerine ointment, diltiazem ointment

botulinum toxin A injection

surgery - lateral internal sphincterotomy

Question 23

Perianal abscess symptoms

Answer 23

pain - increased on walking and straining
fever
malaise
inflammation signs - calor, rubor, dolor, tumour, function laesse

Question 24

Name some locations of anal abscessed

Answer 24

perianal
ischiorectal
supralevator, intersphincteric, submucous
ischiorectal post-anal space

Question 25

Abscesses treatment

Answer 25

surgical drainage - cruciate incision, sometimes a drain may be left

Question 26

What is an anal fistula?

Answer 26

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)

Question 27

What is the difference between a fistula and a sinus?

Answer 27

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

Question 28

Anal fistula symptoms

Answer 28

discharge pain and swelling when fistulas become blocked and abscesses recur irritation causes itching and discomfort

Question 29

Describe Goodsall's rule for anal fistulas

Answer 29

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

Question 30

Fistula treatment

Answer 30

seton fistulotomy fibrin glue fistula plugs LIFT procedure advancement flap

Question 31

Why is there reluctance in performing fistulotomy for fistula in ano despite high success rate?

Answer 31

risk of incontinence

Question 32

What is a pilonidal sinus?

Answer 32

a small hole or 'tunnel' in the skin. It usually develops in the area where the buttocks divide

Question 33

Pruritis ani symptoms and signs

Answer 33

itching burning irritation worse at night reddened, oedematous, ulcerations and excoriations skin atrophic or hypertrophic with associated nodularity and scarring

Question 34

What causes anal warts?

Answer 34

HPV