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Surgery Block > General - Anorectal > Flashcards

General - Anorectal Flashcards

1
Q

Define an anal fissure

A

Tear in the mucosal lining of the anal canal

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2
Q

How are anal fissures classified?

A

Acute: <6wks
Chronic: >6wks

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3
Q

What are the risk factors for anal fissures?

A

Inflammation or trauma to anal canal:

  • Constipation
  • Dehydration
  • IBD
  • Chronic diarrhoea
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4
Q

What are common presenting features of anal fissures?

A
  • Intense pain post defecation (lasting several hours)
  • Bleeding (bright red on wiping)
  • Itching
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5
Q

Where do anal fissures most commonly occur?

A

Posterior midline

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6
Q

How is an anal fissure often diagnosed?

A

DRE conducted anaesthesia

Fissures can be identified upon proctoscopy

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7
Q

How are patients with anal fissures medically managed?

A
  1. Increase of dietary fibre and fluids
  2. Stool softening laxatives (eg. movicol or lactulose)
  3. GTN or diltiazem cream
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8
Q

Why is GTN or diltiazem cream used?

A

Increases blood supply to the region and relaxes the internal anal sphincter –> puts less pressure on the fissure and promotes healing and reducing pain

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9
Q

When is surgical therapy used to treat anal fissures?

A

Chronic fissures where medical treatment has failed

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10
Q

What surgery is indicated for anal fissures?

A

Lateral sphincterotomy

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11
Q

Define an anal fistula

A

An abnormal connection between the anal canal and the perianal skin. Associated with anorectal abscess formation

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12
Q

What risk factors are there for anal fistula formation?

A
  • Anal abscess
  • IBD
  • Systemic disease eg. TB, Diabetes, HIV
  • History of trauma
  • Previous radiation therapy to anal region
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13
Q

What will an anal fistula commonly present with?

A
  • Intermittent or continuous discharge
  • Severe pain
  • Swelling
  • Change in bowel habit
  • Systemic features of infection
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14
Q

What may be found on examination of an anal fissure?

A
  • An external opening on the perineum (fully opened or covered in granulation tissue)
  • Fibrous tract may be felt on DRE
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15
Q

What is the Goodsall rule used for?

A

Used to predict the trajectory of a fistula tract

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16
Q

What does the Goodsall rule predict in a fistula tract with the external opening POSTERIOR to the transverse anal line?

A

Fistula tract will follow a curved course to the posterior midline

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17
Q

What does the Goodsall rule predict in a fistula with an opening ANTERIOR to the transverse anal line?

A

Fistula tract will follow a straight radial course to the dentate line

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18
Q

What imaging modality is indicated for an anal fistula?

A

Rigid sigmoidoscopy - visualised the opening in the tract in the anal canal

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19
Q

Briefly describe Park’s classification system

A
  • Intersphincteric fistula (most common)
  • Transphincteric fistula
  • Suprasphincteric fistula (least common)
  • Extra sphincteric fistula
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20
Q

What surgical treatment is available for anal fistulas?

A
  • Fistulotomy
  • Seton placement
  • +/- Opening perianal skin adjacent to external opening
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21
Q

When should surgery not be performed for an anal fistula?

A
  • If patient is asymptomatic –> conservative

- Acute anorectal abscess

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22
Q

In which types of anal fistulas are there higher risks of incontinece post operatively?

A

High tract course fistula (travels through more subcut tissue and muscle)

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23
Q

What is thought to cause anorectal abscesses?

A

Plugging of the anal canal ducts causing stasis, allowing the normal bacterial flora to overgrow and cause infection

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24
Q

What are the common causative organisms involved in anorectal abscesses?

A

E coli
Bacteriodes
Enterococcus

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25
Q

How are anorectal abscesses catergorised?

A
  • Perianal (most common)
  • Ischiorectal
  • Intersphincteric
  • Supralevator
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26
Q

How will an anorectal abscess typically present?

A
  • Perianal pain, exacerbated when sitting down
  • Localised swelling
  • Itching
  • Discharge
  • Systemic features if severe
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27
Q

Which type of anorectal abscess is most likely to have systemic symptoms?

A

Ischiorectal abscesses

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28
Q

What may be seen on examination of an anorectal abscess?

A

Red and tender abscess, discharging purulent or haemorrhage fluid
May be some surrounding cellulitis

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29
Q

What imaging may be done for complicated anorectal abscesses?

A

MRI scan

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30
Q

Why is there little scope for conservative management of anorectal abscesses?

A

High rates of recurrence and development of fistulae

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31
Q

When may antibiotics be indicated in anorectal abscess management?

A

Acute infective states, especially in diabetics or immunocompromised patients

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32
Q

What management is indicated for anorectal abscesses?

A

Surgical drainage followed by packing

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33
Q

How should an abscess be left to heal?

A

By secondary intention - early closure is not advised

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34
Q

What is pilonidal sinus disease?

A

Disease of the anorectal region, characterised by the formation of a sinus in the cleft of the buttocks

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35
Q

What group of people does pilonidal sinus disease commonly affect?

A

Caucasian males aged 15-30 years

Classically those who sit for prolonged periods of time

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36
Q

Briefly outline the pathophysiology of pilonidal sinus disease

A
  1. Hair follicle in the intergluteal cleft becomes infected or inflamed
  2. Inflammation obstructs the opening of the follicle, which extends inwards to form a pit
  3. Foreign body type reaction can lead to the formation of a cavity, connected to the skin surface
37
Q

What risk factors are there for pilonidal sinus disease?

A
  • Male
  • Coarse, dark body hair
  • Increased sweating
  • Prolonged sitting
  • Friction in buttocks
  • Obesity
  • Poor hygiene
  • Local trauma
38
Q

Describe the classical clinical presentation of pilonidal sinus disease

A

Intermittent red, painful and swollen mass in the sacrococcygeal region
Commonly has discharge +/- systemic symptoms

39
Q

What is the main distinguishing feature between a pilonidal sinus and an anal fistula?

A

Sinus opens up onto the skin but does not continue into the anal canal

40
Q

What imaging method can be used to differentiate between a pilonidal sinus and a fistula?

A

Rigid sigmoidoscopy

41
Q

What is the conservative management for pilonidal sinus disease?

A

Shaving of affected region and plucking the sinus free of any embedded hair

42
Q

What is the management for an acute pilonidal sinus abscess ?

A

Drainage and washout of the abscess

+ later removal of sinus tract

43
Q

How is chronic pilonidal sinus disease managed?

A

Removal of pilonidal sinus tract

44
Q

Over what age does the incidence of pilonidal sinus disease reduce?

A

40 years

45
Q

What is the most common type of anal cancer? Where does this occur?

A

Squamous cell carcinoma - arises below the pectinate line

46
Q

Where do adenocarcinomas in the anus tend to occur?

A

Upper anal canal epithelium and crypt glands

47
Q

What is anal intraepithelial neoplasia?

A

Precedes the development of invasive squamous cell anal cancer. Can affect either the perianal skin or anal canal.

48
Q

What is anal intraepithelial neoplasia linked to?

A

HPV 16 and HPV 18 infection

49
Q

How is anal intraepithelial neoplasia graded?

A

Dependent on the degree of cytological atypical and the depth of it into the dermis

50
Q

At what grade of anal intraepithelial neoplasia do we determine it as premalignant?

A

High grade AIN (2 or 3)

51
Q

What are the risk factors for development of anal cancer?

A
  • HPV infection
  • HIV infection
  • Increasing age
  • Smoking
  • Immunosupressant medication
  • Crohns disease
52
Q

What are the main symptoms of anal cancer?

A
  • Pain
  • Rectal bleeding
  • Anal discharge
  • Pruritus
  • Palpable mass
53
Q

What symptoms might be seen in invasive anal cancer?

A
  • Perianal infection and fistula-in-ano

- Faecal incontinence + tenesmus (if sphincters involved)

54
Q

What should be looked for on examination of suspected anal cancer?

A
  • Ulceration of the perineum and perianal region
  • Wart like lesions
  • Vaginal examination
  • DRE (if possible)
55
Q

What should be documented about a DRE for anal cancer?

A

Distance of the mass from the anal verge + fraction of anal circumference it occupies

56
Q

What are the main differential diagnoses for anal pathology?

A
  • Haemorrhoids
  • Anal fissure
  • Fistula in ano
  • Anal warts
  • Low rectal cancer
  • Skin cancer
57
Q

What investigation can be done to visualise the anal canal?

A

Proctoscopy

58
Q

What definitive diagnostic investigation should be done for all patients with suspected anal cancer?

A

Examination under anaesthetic with a biopsy for histology

59
Q

Why should a smear test be done in females with suspected anal cancer?

A

To exclude cervical intraepithelial neoplasia (CIN)

60
Q

What imaging is required for staging of anal cancer?

A
  • USS guided fine needle aspirate of any palpable inguinal lymph nodes
  • CT thorax-abdo-pelvis (for mets)
  • MRI pelvis (assess extent of local invasion)
61
Q

What is first line management for anal cancer?

A

Chemo-radiotherapy

–> external beam radiotherapy into anal canal and inguinal nodes + dual chemotherapy agents

62
Q

When is surgical excision of an anal cancer indicated?

A
  • Advanced disease
  • After failure of chemo-radiotherapy
  • Early T10 carcinoma
63
Q

What surgical approach is used for excision of anal cancers?

A

Abdominoperineal resection

64
Q

When do recurrences of anal cancer tend to occur?

A

Within the first 3 years

65
Q

What short term complications are there of anal cancer?

A

Chemoradiation related pelvic toxicity:

  • Dermatitis
  • Diarrhoea
  • Procitits
  • Cystitis
  • Leucopenia
  • Thrombocytopenia
66
Q

What long term complications are there of anal cancer?

A
  • Fertility issues
  • Faecal incontinence
  • Vaginal dryness
  • Erectile dysfunction
  • Rectovaginal fistula
67
Q

Define a haemorrhoid

A

An abnormal swelling or enlargement of the anal vascular cushions

68
Q

What are the anal vascular cushions?

A

Assist the anal sphincter in maintaining continence

There are 3 : 3, 7 and 11 o’clock positions (if anterior is 12)

69
Q

Briefly describe the classification of haemorrhoids

A

1st degree: Remain in the rectum

2nd: Prolapse through the anus on defecation but spontaneously reduce
3rd: Prolapse through the anus on defecation but require digital reduction
4th: Remain persistently prolapsed

70
Q

What are the risk factors for haemorrhoids?

A
  • Excessive straining
  • Increasing age
  • Raised intra abdominal pressure
  • Pelvic/abdo masses
  • FHx
  • Cardiac failure
  • Portal hypertension
71
Q

What is the typical presentation of a haemorrhoid?

A
  • Painless bright rectal bleeding - commonly after defecation + seen on paper or covering the pan (ie. not mixed in)
  • Pruritus
  • Rectal fullness
  • Soiling
72
Q

What may happen to a large, prolapsed haemorrhoid?

A

They can thrombose - very painful and can be an emergency

73
Q

What will a thrombosed prolapsed haemorrhoid look like?

A

A purple/blue, oedematous, tense and tender perianal mass

74
Q

What investigation is used to confirm haemorrhoids?

A

Proctoscopy

75
Q

What non surgical management can be given for haemorrhoids?

A
  • Rubber band ligation *
  • Infrared coagulation/photocoagulation
  • Bipolar diathermy
  • Direct-current electrotherapy
76
Q

What surgical option is there for haemorrhoids?

A

Haemorrhoidectomy (stapled or Milligan Morgan)

77
Q

What are the main complications of haemorrhoidectomy?

A
  • Bleeding
  • Infection
  • Constipation
  • Stricture
  • Anal fissures
  • Faecal incontinence
78
Q

What complications are there of haemorrhoids?

A
  • Thrombosis
  • Ulceration
  • Gangrene
  • Skin tags
  • Perianal sepsis
79
Q

What is a rectal prolapse?

A

Where a mucosal or full-thickness layer of rectal tissue protrudes out of the anus

80
Q

What are the two main types of rectal prolapse?

A
  • Partial thickness (rectal mucosa protrudes out of anus)

- Full thickness (rectal wall protrudes out of anus)

81
Q

What is the pathophysiology of a full thickness rectal prolapse?

A

Form of sliding hernia through a defect of the fascia of the pelvic region
Caused by chronic straining

82
Q

What is the pathophysiology of a partial thickness rectal prolapse?

A

Associated with loosening and stretching of the CT attaching the rectal mucosa to the remainder of the rectal wall
(often in conjunction with haemorrhoids)

83
Q

What is the typical presentation of a rectal prolapse?

A
  • Rectal mucous discharge
  • Faecal soiling
  • Bright red blood on wiping
  • Visible ulceration possible
84
Q

What may a full thickness prolapse present with if internal?

A
  • Sensation of rectal fullness
  • Tenesmus
  • Repeated defecation
85
Q

How can a prolapse be identified on examination?

A

Asking the patient to strain

DRE - assess for weakened sphincter tone

86
Q

What can be used to identify an internal prolapse?

A

Defecating proctography + examination under anaesthesia

87
Q

What is the definitive management of a rectal prolapse?

A

Surgical repair - either abdominal or perianal procedure

88
Q

What is the abdominal approach to surgical repair of a rectal prolapse?

A

Rectopexy - mobilisation of rectum and fixing onto sacral prominence

89
Q

What are the two operations that can be used for a perianal approach to repair of a rectal prolapse?

A

Delormes

Altmiers (more effective

Surgery Block (12 decks)

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