Anorectal disorders Flashcards
Give examples of congenital ano-rectal abnormalities
Imperforate anus
Uro-Genital Fistulae
Hirschprung’s Myenteric Plexus Deficiency
Common presentations of an ano-rectal disorder?
pain
haemorrhage
dysfunction
What are 4 common root causes of ano-rectal disorders?
Inflammation
Infection
Malignancy
Trauma
Examples of acquired ano-rectal abnormalities? (7)
Haemorrhoids Fissure Abscess Fistula-in-ano Ulceration Cancer Control of Continence
What causes heamorrhoids
Increased pressure/congestion in the blood vessels around the anal canal
What is the aetiology of haemorrhoids?
Unknown
Associated with straining or constipation
What are the symptoms of haemorrhoids?
Bright red rectal bleeding - painless
Pruritis ani
Mucus discharge
What is the treatment of haemorrhoids?
Treat underlying cause ie constipation
Out patient - Rubber band ligation - internal hemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the hemorrhoid
Surgical:-
HALO - haemarroidal artery ligation op
Anopexy - staple - done if patient has prolapse (pushing out the rectum) and haemorrhoids
Haemorrhoidectomy
What is the cause of anal fissures?
Trauma or ischaemia
What is an anal fissure?
Superficial mucosal tear of the anus most commonly in the midline posteriorly
can be sign of anal cancer
What are the symptoms of anal fissures?
Pain on defacation
Minor bleeding
Mucus discharge and pruritis
Odematous skin tag / ‘sentinal pile’ may be present next to the fissure
Treatment for anal fissures requires relaxing the internal anal sphincter, how is this done?
Underlying cause - constipation
Medical
GTN/diltiazem + Lignocaine
Surgical
Sphincterotomy
Botox
What happens as a result of the tension of the internal anal sphincter being too high?
The internal anal sphincter is always under tension, also known as resting pressure. If that pressure becomes too high, a fissure may form or an existing one may not heal.
In surgical anal sphincterectomy - an incision reduces the resting pressure, allowing the fissure to heal.
Where do ischiorectal abscess occur? and how do they normally develop?
Lateral to the sphincters in the ischiorectal fossa
Infection of the anal glands by normal intestinal bacteria or
Crohn’s disease is sometimes responsible
What are the symptoms of perianal fistulae?
Extreme perianal pain, fever and discharge of pus
signs of sepsis
Risk factors of perianal abscess
diabetes
BMI
immunosuprression
trauma
How are abscesses treated?
Antibiotics if septic
Surgical incision and drainage
What is a fistula in ano?
An anal fistula can be described as a narrow tunnel with its internal opening in the anal canal and its external opening in the skin near the anus
Where do anal fistula form?
Anal fistulae originate from the anal glands, which are located between the internal and external anal sphincter and drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually extend to the skin surface. The tract formed by this process is a fistula
What are the symptoms/complications associated with anal fistula? (4)
Painful
Peri-anal sepsis
Persisting pus discharge with flare up
+/- fecal soiling - formed stools can also pass through the fistula
Treatment of fistula in ano
very difficult to treat
surgical - 50% failure rate
seton - drain sepsis/mature tract
sphincter preservation techniques
Lay open - Simple fistulas can be ‘laid open’ by cutting a small amount of the anal skin and muscle to open up the tract. Risk of impairment of continence is particularly worrying in women
What percentage of colorectal cancers are in the rectum and anus?
Rectum: 16%
Anus: 3%
What is treatment for anal squamous cancer?
Radiotherapy
What is the treatment for rectal adenocarcinoma?
Neo adjuvant ChemoRad (chemo and radiotherapy)
Laparoscopic Resection
What are the causes of anal ulceration?
Crohn’s Disease
Malignancy
Syphilis “Chancre”
Nicorandil - used for angina
What are common causes of faecal incontinence?
Severe diarrhoea
Anorectal disease - haemorrhoids, rectal prolapse, Crohn’s
Neurological conditions - spinal cord/cuada equina legions
Dementia
What does the function of the anorectum require? (3)
Pelvic floor
rectal compliance
intact pelvic neurology
What does the anorectum do? (2)
controls defaecation
maintenance of continence
What is anopexy
removal of abnormally enlarged hemorrhoidal tissue, followed by the repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position
Symptoms/signs of Anal/rectal cancer (5)
Painful/painless
Bleeding
Indurated - hardened mass/formation
Red flag signs
FIT test +ve - screening - fecal immunochemical test
Routine investigations for anal/rectal cancer (7)
PR examination - rectal
Proctoscopy - camera up rectum
Rigid sigmoidoscopy - light and glass window
Colonoscopy/flexi sigmoidoscopy
CT colonoscopy
CT scan
MRI rectum
What is pelvic floor dysfunction
Collection of wide spectrum of symptoms related to defecation
Obscure symptomatology
Often a fear of more serious illnesses
Embarrassment and hesitation to come up with real issues
May have a history of abuse
Social limitation
What are the 2 broad categories of causes of pelvic floor dysfunction
child-birth related
all other causes - surgery, abuse, perianal sepsis, low anterior resection syndrome (LARS)
Who can get pelvic floor dysfunction?
predominantly women - either parous (having had children)
also men and non-parous women due to things like surgery, neurological/Connective Tissue disorders or psychological/behavioural issues
Chronic constipation types (4)
Dietary (commonest)
Drugs
Organic - Hirshsprung or EDS
Functional - Slow transit (infrequent), Evacuation related (Common) or Combination (slow transit as a result of evacuatory dysfunction)
Drugs causing constipation
aluminium antacids
antidepressants - tricyclic
antiepileptics
antipsychotics
opioids
How to assess chronic constipation
Colonoscopy/ CT colon
baseline bloods to exclude anaemia
symptomatic FIT test
coeliac serology
colonic transit studies
detailed history
What is Hirshsprung
Birth defect
absence of particular nerve cells (ganglions) in bowel of an infant
How to treat chronic constipation
Start with regular baseline laxatives
Ensure compliance
Consider combination therapy
surgical options for slow transit - colectomy etc
Faecal incontinence types (4)
Passive: Internal sphincter defect
Urge: Rectal pathology, functional
Mixed: Prolapse
Overflow: Constipation
What is anal manometry used for?
to test rectal function
what is the best modality to assess anatomy and dynamic function of
defaecating proctogram - uses X-ray
provides info on Pelvic floor mobility, Pathological function of the musculature etc
Aggressive conservative measures to manage FI
Low fibre diet Loperamide Pelvic floor exercises EMG if required Irrigation Anal plug
Surgery options for FI
Sphincter repair
Correct anatomical defect
Sacral nerve stimulator
Anal bulking agent for passive FI
- Permacol
- GateKeeper
- SphinKeeper
