Benign colorectal conditions Flashcards
Anorectal anatomy - look at pics:
How long is the rectum?
How long is the anal canal?
What type of muscle is the internal sphincter?
What type of control is used for the internal sphincter?
What nerve controls the external sphincter?
What muscle blends with the external sphincter?
15cm long
3.5cm long
Circular muscle
Parasympathetic
Pudendal nerve (S4)
Puborectalis muscle
Anorectal abscess:
What is obstructed causing the abscess?
Pathophysiology
Anal glands/crypts
6-10 structures at the dentate line of unclear function - and subsequent infection by gut bacteria
Anorectal abscess:
Most in perianal location. Where is this?
It can also be found:
- Ischiorectally
- Intersphincterically
- Supralevator
Limited to the skin of the anal canal (subcutaneous)
Crosses the external anal sphincter
Between internal and external sphincters
Superior extension above the levator ani
Anorectal abscess:
What leads to fistula formation in 50% of cases?
Rupture (spontaneous or surgical)
Anorectal abscess - risk factors:
- Bowel inflammation - 4
- Immunosuppression - 2
- Trauma - 2
- Demographic and social - 2
IBD - Crohns Diverticulitis TB Hidradentis suppurativa ---- DM HIV ------ Rectal foreign bodies Receptive anal sex ----- Male Age 20-60
Anorectal abscess - Presentation:
What would be the 2 main symptoms?
When may the symptoms be worse? - 2
What may happen as a result of the symptoms?
What may deeper abscesses cause?
Perianal pain and pruritus
Worse on sitting and defecation
Constipation due to painful defecation
Systemic illness
Anorectal abscess - Examination:
What may be found on DRE? - 2
What can be done if there is too much pain?
What imaging could be done for deeper abscesses?
Perianal swelling
Purulent/bloody discharge
Put them under general anaesthesia
Endoanal US or MRI
Anorectal abscess - Management is incision and drainage:
Where can it be done?
What is required if more complex?
Most wounds can be left open without packing. What will an intersphinteric abscess require?
What is advised after the procedure?
What can be given to help with the pain of defecation?
Ward or ED
Theatre
Post-op drain
Sitz bath (bath only to hip to clean perineum)
Laxative
Anal fistula:
What is it?
What does it most commonly happen after?
What are some other causes:
- IBD - 1
- Infection - 2
- Malignancy and Rx - 2
- Trauma -3
Abnormal communication between 2 epithelial surfaces (e.g. anal canal and the perianal skin)
Drainage or rupture of anorectal abscess
Crohns
TB, HIV
Rectal cancer or radiotherapy
Foreign body
Iatrogenic
Anal fissure
Anal fistula - classification:
Define:
- Intersphincteric - most common - 70%
- Transphincteric
- Suprasphincteric
- Extrasphincteric
The tract begins in the space between the internal and external sphincter muscles and opens very close to the anal opening.
The tract begins in the space between the internal and external sphincter muscles or in the space behind the anus. It then crosses the external sphincter and opens an inch or two outside the anal opening. These can wrap around the body in a U shape, with external openings on both sides of the anus (called a horseshoe fistula).
The tract begins in the space between the internal and external sphincter muscles and turns upward to a point above the puborectal muscle, crosses this muscle, then extends downward between the puborectal and levator ani muscle and opens an inch or two outside the anus.
The tract begins at the rectum or sigmoid colon and extends downward, passes through the levator ani muscle and opens around the anus. These fistulas are usually caused by an appendiceal abscess, diverticular abscess or Crohn’s disease.
Anal fistula - presentation - symptoms are persistent:
Main symptoms - 3
What may happen if it is left untreated? - 2
Rectal pain made worse by sittng and defecation
Discharge (continuous or intermittent) and soiling
Pruritus
Sepsis
Anatomical changes leading to incontinence
Anal fistula - most diagnosed clinically:
What imaging can be used?
Endoanal USS
MRI
Anal fistula - management:
Low fistula tract - 2 options:
- Surgery
- Injection of what?
Fistulotomy - fistula is opened by and allowed to heal by secondary intention
Injection of fibrin glue/sealant
Anal fistula - management:
High fistula tract - 4 options:
- Surgery + seton cord
- What are advancements flaps?
- What can also be put in place to stop leakage?
- What does LIFT stand for?
Fistulotomy and placement of seton cord which is left in fistula to allow drainage during the healing
Adjacent mucosa used to seal internal opening - look at pics
Fistula plug - look at pics
Ligation of intersphincteric fistula tract - look at pics
Anal fissure:
What is it?
What position are they usually found in using the lithotomy position?
Causes:
- Common cause
- Women
- Anal
- Inflammation
Longitudinal ulcer in the anal canal, anywhere from below the dentate line to the anal margin.
6’clock position - same direction as the sagittal plane
Straining constipation
Childbirth
Trauma
IBD
Anal fissure - Management:
Initial advice for:
- Bowel movements
- Constipation - 2
- Cleaning
Avoid straining
Increase fibre and fluid intake
Consider laxative
Immense anus warm water with swallow bath
Sitz birth kit 2 - 3 days daily
Anal fissure - Management - Topical medical Rx:
GTN 0.4% - What does it stand for? MOA? (2)
Diltiazem 2% - MOA?
Last topical option - Simon Cowell
Glyceryl trinitrate - Relieves pain and relaxes sphincter allowing more blood flow aiding healing
Relieves pain and relaxes sphincter allowing more blood flow aiding healing
Botox
Anal fissure - Management - Surgical:
Lateral anal sphincterotomy - what is it?
Excision and anal advancement flap - what is it?
The surgeon will then make a small cut in the sphincter to relax it and stop it going into spasm. This will allow the fissure to heal.
Basically remove the fissure and you take some extra skin to replace it
Haemorrhoids:
What is it?
What are anal vascular cushions?
What positions are they usually found in using the lithotomy position?
Enlarged symptomatic anal vascular cushions
Part of normal anatomy that contains arteriovenous channels - that connect superior rectal artery and vein - sitting with smooth muscle, submucosal fibroelastic connective tissue and mucosa
3, 7 and 11 o’clock
Haemorrhoids:
What age group is commonly affected?
What bowel problem may cause them?
Women?
Middle age
Constipation
Pregnancy
Haemorrhoids:
Classification - grades of internal haemorrhoids - 4
What are the external haemorrhoids below?
- Never prolapse
- Prolapse and reduce spontaneously
- Prolapse and require manual reduction
- Irreducible
The dentate line
Haemorrhoids:
Main symptoms - 2
They are usually painless. When can they be painful? - 2
What other symptoms may occur? - 2
Bright red bleeding on toilet paper or surface of the stool
Itchy
Thrombosed external haemorrhoids and prolapsed strangulated internal haemorrhoids
Mucus or faecal soiling
Haemorrhoids:
Investigations:
What exam is needed?
What can be used to examine the haemorrhoids?
What should be done to exclude other pathology?
DRE
Proctoscope
Colonoscopy
Haemorrhoids - Management:
Advice - 2
What topical cream can be given if painful?
When are more interventions needed?
Avoid straining
Soften stools - laxatives, fibre and fluids
Topical local anaesthetic cream
Thrombosed, strangulated or symptomatic despite other measures
Haemorrhoids - Management - Surgery:
What surgery can be done for painful, thrombosed external haemorrhoids presenting within 72 years?
You can do a rubber band ligation via endoscopy for internal haemorrhoids. Why cannot be done for external ones?
Excision
External haemorrhoids have a normal sensory supply so they’ll feel pain
Haemorrhoids - Management - Surgery:
What is done to prevent reoccurrence?
What is an alternative that doesn’t last as long?
Open haemorrhoidectomy however very painful.
Stapling or haemorrhoid arterial ligation - less painful than open
Rectal Prolapse:
Define
3 types
Who does it tend to occur in?
Protrusion of rectum through the anal opening
Partial - mucosa only
Complete - Full thickness of the rectum
Internal - intussusception
Post-menopausal women
Rectal Prolapse:
One symptom
Management - conservative - 1
Management of mucosal prolapse - 1
Mass that appears on defecation
Avoid straining
Rubber band ligation or stapling
Rectal Prolapse - Management of full-thickness prolapse:
Perianal approach:
Less invasive - What is DeLorme’s procedure?
2nd line - What is Altemieier’s procedure?
The mucosa is removed close to the dentate line and the mucosal boundaries are sutured together
Full-thickness rectal resection
Rectal Prolapse - Management of full-thickness prolapse:
Abdominal approach:
What a laparoscopic ventral rectoplexy?
The rectum is stitched to the wall
Faecal incontinence:
Causes:
- Obstetric trauma
- Scars
- Disease
High parity
Instrumental delivery
Episiotomy
Lower GI surgery
Colonic or perianal disease, including cancer and fistulas
Faecal incontinence:
What exam should be done and what specifically should be checked?
What imaging should be done? - 2
DRE - anorectal physiology - anal tone, perianal sensation
Flexible sigmoid or colonoscopy
Endoanal USS
Faecal incontinence - Management:
Underlying causes treated first!!!!
What can be given to prevent diarrhoea?
What physical instrument can be put in place?
3 surgical options?
Treat underlying cause
Antidiarrhoaels - loperamide and codeine
Anal plug
Sphincter repair
Sacral nerve stimulation
Stoma
Anal itching:
What is the medical name for it?
Pruritus ani
Anal itching - Causes:
- Colorectal - 7
- Dermatological - 2
- Infection - 5
- Inflammatory - 2
- Multisystem - 4
Diarrhoea Constipation Haemorrhoids Fissures Fistulas Cancer Prolapse ---- Eczema Psoriasis ---- Candida Anogenital warts Tinea cruris - jock itch Gonorrhoea Threadworm (nocturnal itch) ----- Crohns HS ---- DM Thyroid disease Liver disease - bile acid Polycythemia vera
Anal itching:
Underlying causes treated first!!!!
Patient advice - 4
What can be prescribed if the perianal skin is inflamed and there is no fungal infection?
Avoid itching and excess wiping
Washing with plain water
Gently patting dry
Identify and avoid triggers (e.g. soaps, detergents, fabrics)
Hydrocortisone 1%
