Anorectal disorders Flashcards by Anna Coull

Give examples of congenital ano-rectal abnormalities

Imperforate anus

Uro-Genital Fistulae

Hirschprung’s Myenteric Plexus Deficiency

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Common presentations of an ano-rectal disorder?

pain
haemorrhage
dysfunction

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What are 4 common root causes of ano-rectal disorders?

Inflammation
Infection
Malignancy
Trauma

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Examples of acquired ano-rectal abnormalities? (7)

Haemorrhoids
Fissure
Abscess
Fistula-in-ano
Ulceration
Cancer
Control of Continence

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What causes heamorrhoids

Increased pressure/congestion in the blood vessels around the anal canal

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What is the aetiology of haemorrhoids?

Unknown

Associated with straining or constipation

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What are the symptoms of haemorrhoids?

Bright red rectal bleeding - painless

Pruritis ani

Mucus discharge

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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

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What is the cause of anal fissures?

Trauma or ischaemia

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What is an anal fissure?

Superficial mucosal tear of the anus most commonly in the midline posteriorly

can be sign of anal cancer

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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

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Treatment for anal fissures requires relaxing the internal anal sphincter, how is this done?

Underlying cause - constipation

Medical
GTN/diltiazem + Lignocaine

Surgical
Sphincterotomy
Botox

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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.

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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

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What are the symptoms of perianal fistulae?

Extreme perianal pain, fever and discharge of pus

signs of sepsis

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Risk factors of perianal abscess

diabetes
BMI
immunosuprression
trauma

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How are abscesses treated?

Antibiotics if septic

Surgical incision and drainage

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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