Colorectal surgery: Anal fissures; Diverticulitis

Question 1

Define what is meant by an anal fissure [1]

Answer 1

Anal fissure is a split in the skin of the distal anal canal characterised by pain on defecation and rectal bleeding.

They are longitudinal or elliptical tears of the squamous lining of the distal anal canal

Question 2

What makes an anal fissure acute or chronic? [1]

Answer 2

Acute: less than 6 weeks
Chronic: more than 6 weeks

Question 3

What are risk factors for anal fissures? [5]

Answer 3

constipation
inflammatory bowel disease
sexually transmitted infections e.g. HIV, syphilis, herpes
pregnancy
opiate analgesia

Question 4

Describe the treatment algorithm for acute fissures

Answer 4

1st line: soften stool
- high fibre intak
- Bulk forming laxatives
- lubricants like petroleum jelly

2nd line:
- Glyceryl trinitrate

3rd line:
- topical diltiazem (if headaches from glyceryl trinitrate are too much)

Question 5

Why might glyceral trinitrate cause headaches? [1]

Answer 5

Some patients experience a headache due to glyceryl trinitrate entering the bloodstream and causing cerebral vasodilatation

Question 6

Describe the treatment algorithm for chronic anal fissures [3]

Answer 6

topical glyceryl trinitrate (GTN) is first-line treatment for a chronic anal fissure

Botulinum toxin or sphincterotomy is used after failure of topical treatment for 8 weeks

sphincterotomy:
The operation usually takes about 15 minutes. Your surgeon will make a small cut on the skin near your back passage. They will cut the lower part of the internal sphincter muscle. This will relieve the spasm in the sphincter, allowing a better blood supply to heal the fissure.

Question 7

almost all diverticula are found in the []

Answer 7

almost all diverticula are found in the sigmoid colon

Question 8

Which patient population are diverticuli likely to be found in right colon? [1]

Answer 8

Asian patients

Question 9

Patients with diverticular disease typically present with a chronic history of what? [3]

Answer 9

Intermittent abdominal pain: particularly in the left lower quadrant
Bloating
Change in bowel habit: constipation or diarrhoea

Question 10

How does acute diverticulitis present? [5]

Answer 10

Severe abdo pain in LLQ
N&V
Constipation (more common than diarrhoea)
Urinary frequency & urgency
PR bleeding

Question 11

How do you determine diverticultis vs UC?

Answer 11

UC:
- Bloody diarrhoea

Diverticultis:
- Fever
- Constipation
- LLQ pain

Question 12

Describe two symptoms of complications of diverticulitis [2]

Answer 12

pneumaturia or faecaluria may suggest a colovesical fistula
vaginal passage of faeces or flatus may suggest a colovaginal fistula

Question 13

What might erect CXR show in a ptx with divertcultis? [1]

Answer 13

pneumoperitoneum in cases of perforation

Question 14

Which investigation method should be avoided in diverticulosis and why? [2]

Answer 14

Colonoscopy: should be avoided initially due to the increased risk of perforation in diverticulitis

Question 15

What might an AXR show in diverticulosis? [3]

Answer 15

AXR: may show dilated bowel loops, obstruction or abscesses

Question 16

Describe the treatment regime for diverticulitis? [4]

Answer 16

mild cases of acute diverticulitis may be managed with oral antibiotics, liquid diet and analgesia CKS

dicycloverine: antispasmodic

if the symptoms don’t settle within 72 hours, or the patient initially presents with more severe symptoms, the patient should be admitted to hospital for IV antibiotics

Consider open or laparoscopic resection for patients who have recovered from complicated acute diverticulitis but have continuing symptoms (such as stricture or fistula)

Question 17

What is a thrombosed haemorrhoid? [1]

How do you determine if an anal presentation is a thrombosed haemorrhoid? [3]

Answer 17

Thrombosed haemorrhoids occur when either an internal or external hemorrhoid fills with blood clots.

Thrombosed haemorrhoids are characterised by anorectal pain and a tender lump on the anal margin. It does not normally present with bleeding but this can occur if the haematoma spontaneously bursts.

Question 18

An anal longintudinal tear and fresh rectal bleeding is the diagnosis of? [1]

Answer 18

Anal fissure

Question 19

What is an anal fistula? [1]

Answer 19

abnormal connection that develops between the perianal skin and the anal or rectal lumen.

Question 20

Research anal fissure / haemorrhoid / anal abscess treatments and make flashcards