Anorectal disorders Flashcards
What is pruritis ani?
Itch that occurs around the anus
What can cause pruritis ani?
- Moist/solied anus
- Fissures
- Incontinence
- Poor hygeine
- Tight pants
- Threadworm
- Fistula
- Dermatoses
- Lichen sclerosis
- Anxiety
- Contact dermatitis
How would you treat someone with pruritis ani?
- Avoid scratching
- Improve perianal hygeine
- Avoid foods which loosen stool
- Soothing ointment
- Topical steroids (max 2 weeks)
- Oral antihistamine
What are anal fissures?
Painful tears in the squamous lining of the lower anal canal. Often, if chronic, they will have a sentinal pile or mucosal tag at the external aspect
What sex do anal fissures occur more commonly in?
Males
What are causes of anal fissures?
- Hard stools - most common
- Syphillis
- Herpes
- Trauma
- Crohn’s
- Anal cancer
- Psoriasis
Why do anal fissures take a significant amount of time to heal?
Spasm around the area leads to relative ischaemia, meaning that fissures take longer to heal
What might you consider doing in someone with anal fissures if you suspected a sinister cause?
Proctoscopy/Sigmoidoscopy
How would you manage someone with anal fissures?
- Dietary fibre
- Fluids
- Stool softener
- Hygeine advice
-
Consider medical
- Topical 5% lidocaine + 0.2% GTN Paste
- Topical 2% Diltiazem
What medical treatment can be used to treat anal fissures?
- Topical 5% lidocaine + 0.2% GTN Paste
- Topical 2% Diltiazem
What would you consider dioing in a patient with anal fissures where conservative and medical management has failed?
Lateral partial internal sphinterectomy
What is a anorectal abscess?
Abscess which is usually caused by gut bacteria, which can occur in the perianal, ischiorectal, intersphincteric or supralevator regions
How would you manage a perianal abscess?
Incise and drain under GA
What diseases are perianal abscesses associated with?
- Diabetes mellitus
- CRohn’s
- Malignancy
- Fistulae
What is a fistula in ano?
A track communicating between the skin and anal canal/rectum. Often occurs following the development of an abscess
How do fistulae in ano form?
Blockage of deep intramuscular gland ducts thought to predispose to the formation of abscesses, which discharge to form fistulas
What are causes of fistula-in-ano?
- Perianal sepsis
- Abscesses
- Crohn’s Disease
- TB
- Diverticular disease
- Rectal carcinoma
- Immunocompromise
What is the following type of fistula-in-ano?
Transphincteric fistula
What is the following type of fistula-in-ano?
Intersphincteric fistula
What type of fistula-in-ano is the following?
Extrasphincteric fistula
What type of fistula-in-ano is the following?
Suprasphincteric fistula
How would you investigate a fistula in ano?
- MRI
- Endoanal US scan
How would you manage someone with fistula-in-ano?
-
Fistulotomy + excision
- High (transphincteric)- seton suturing tightened over time to maintain continence
- Low (superficial) - heal by secondary intention
What are causes of anal ulceration?
- Crohn’s
- Anal cancer
- Lymphogranuloma venerum
- TB
- Syphillis
What is a pilonidal sinus?
Obstruction of the natal cleft hair follicles approximately 6 cm above the anus. In growing hair excites a foreign body reaction and may cause secondary tracks to open laterally, with abscesses extruding foul, smelly discharge
What sex does pilonidal sinuses occur most commonly in?
Males
What percentage fo those with rectal prolapse are incontinent?
75%
Why does rectal prolapse occur?
Lax sphincter, combined with prolonged straining. It is also related to chronic neurological and psycholoigical disorders
How would you manage someone with rectal prolapse?
- Abdominal approach - fix rectum to sacrum (rectoplexy) +/- mesh insertion +/- rectosigmoidectomy
- Perineal approach - Delorme’s procedure - resect close to dentate line and suture mucosal bouncaries
What are risk factors for the development of anal cancer?
- Anoreceptive intercourse
- HPV
- HIV
Where do anal tumours above the dentate line spread to?
Pelvic lymph nodes
Where do anal cancers spread to if they are below the dentate line?
Inguinal lymph nodes
How do those with anal cancer tend to present?
- Bleeding
- Pain
- Bowel habit change
- Pruritis ani
- Masses
- Stricture
How would you manage someone with anal cancer?
- Chemoradiotherapy - radio + flourouracil + mitomycin/cisplatin
- Consider surgery
What are haemorrhoids?
Disrupted and dilated anal cushions. The anus is lined mainly by discontinuous masses of spongy vascular tissue - anal cushions - which contribute to anal closure. These are prone to disruption and displacement, and can protrude forming piles
Trauma to these piles can lead to leaking of the capillaries of underlying lamina propria
PILES ARE NOT VARICOSE VEINS
Why are haemorrhoids above the dentate line not normally painful
No sensory fibres above the dentate line - not painful unless they thrombose and are gripped by anal sphincter
What are causes of haemorrhoids?
- Constipation with prolonged staining - main cause
- Congestion - pelvic tumour
- Pregnancy
- CCF
- Portal hypertension
What is the pathogenesis of haemorrhoids?
VAscular cushion protrudes through the tight anus, becomes more congested, and hypertrophy to protrude again more readily. These protrusions may then strangulate
What are symptoms of haemorrhoids?
- Bright red rectal bleeding - often coating stools/on tissue/dripping into toilet
- Mucous
- Pruritis ani
- Pain
- Severe anaemia can occur
What features might suggest a more sinister cause of what you initially think are haemorrhoids?
- WEight loss
- Tenesmus
- Change in bowel habit
Whaat are important aspects of the examination that you need to consider when examining someone with suspected haemorroids?
- Abdo exam - look for sinister pathology
- PR exam - prolapsing piles, other pathology
- Colonoscopy/flexible sigmoidoscopy if proximal pathology suspected
What is classed as a first degree haemorrhoid?
Remains in the rectum
What is classed as a 2nd degree haemorrhoid?
Prolapse through the anus on defecation but spontaneously reduce
What is classed as a 3rd degree haemorrhoid?
Prolapse on defecation but require digital reduction
What is classed as a 4th degree haemorrhoid?
Remain persistently prolapsed
Where do internal haemorrhoids originate from?
Above the dentate line
Where do external haemorrhoids originate from?
Below dentate line
Where do mixed haemorrhoids originate from?
Both above and below dentate line
How would you manage haemorrhoids?
Conservative/Medical - 1st degree
- High fibre diet + fluids
- Topical analgesia
- Stool softeners
Interventional - 2nd and 3rd degree
- Sclerotherapy
- Band ligation
- Infrared coagulation
- Bipolar diathermy
Surgical
- Excisional Haemorrhoidectomy
- Stapled haemorrhoidopexy
