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MBBS IV - Junior Clerkship WCS > JC62 (Surgery) - Anorectal diseases > Flashcards

JC62 (Surgery) - Anorectal diseases Flashcards

1
Q

Common S/S of anorectal diseases

A
  • Bleeding (fresh)
  • Anal pain
  • Discharge (bloody or purulent)
  • Prolapse
  • Peranal mass
  • Pruritis ani
  • Incontinence
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2
Q

Outline P/E for anorectal diseases

A

General exam

Abdominal exam

Perianal exam

Digital rectal exam

Proctoscopy

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3
Q

Investigations for anorectal diseases

  • Imaging
  • Physiological tests
A

Imaging:

  • Rigid sigmoidoscopy
  • Flexible endoscopy
  • Transrectal ultrasound
  • MRI: complicated abscesses/ fistulas
  • Others (old, superceded): Defecography, Fistulogram

Physiological: constipation and incontinence

  • Anorectal manometry
  • Electromyogram
  • Pudendal nerve latency test
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4
Q

Indications for transrectal ultrasound

A

Staging rectal cancer

Assess sphincter muscles in fecal incontinence

Assess complex fistula

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5
Q

Hemorrhoids

  • Definition
  • physiological function
A

Cushions of vascular tissue at anal canal

Physiological functions:

  • Continence
  • Protect sphincters/ anus from trauma of defecation
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6
Q

Differentiate external and internal hemorrhoids

  • Anatomical division
  • Pain sensation or not
  • Histological differences
A

Internal hemorrhoids
• Above the dentate line with columnar epithelium (i.e. mucosa)
• Receive visceral innervation which is less sensitive to pain and irritation
• Characteristically lie in 3, 7, 11 o’clock positions
•Columnar epithelium (Adenocarcinoma)

External hemorrhoids
• Below the dentate line with squamous epithelium (i.e. skin)
• Surrounds the anal verge and are not true hemorrhoids
• Receive somatic innervation which is more sensitive to pain and irritation
• Stratified squamous epithelium (SCC)

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7
Q

Compare the epithelium, nerve supply, venous drainage and LN drainage of upper and lower anal canal

A
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8
Q

Hemorroids

Causes/ etiologies

A
  1. Risk factors
     Low fibre diet
     Family history of hemorrhoids
2. Increased intra-abdominal pressure
 Pregnancy
 Constipation, straining
 Chronic cough
 Obesity
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9
Q

Classify internal hemorrhoid severity

A

Four degrees of internal hemorrhoids
 1st degree: Bleeding only without prolapse
 2nd degree: Prolapse at defecation but reduce spontaneously afterwards
 3rd degree: Prolapse and have to be manually reduced
 4th degree: Permanently prolapsed, Cannot reduce

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10
Q

S/S of hemorrhoids

A

 Irritation or pruritus
 Bright-red painless bleeding (ALWAYS exclude other possible sources of PR bleeding)
 Mucous discharge
 Prolapsed mass
 Pain (from complications like thrombosis, prolapse)

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11
Q

Treatment plans for different severities of hemorrhoids

A
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12
Q

Non-surgical/ non-operative treatment of haemorrhoids

A

Diet modification: High fiber diet

Sitz bath: relax sphincter muscles and reduce spasm, pruritis, inflammation
For significant haemorrhoids with prolapse

Ointment and suppositories

  • Analgesic cream: mixed lidocaine/ hydrocortisone
  • Hydrocortisone suppositories: shrink hemorrhoids
  • Venoactive agents: Phlebotonics e.g. Daflon to control bleeding

Laxatives/ Stool softeners

  • Osmotic laxative e.g. Lactulose
  • Bulk laxative e.g. Methycellulose
  • Stimulant laxative e.g. Senna/ Bisacodyl
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13
Q

Operative/ Surgical treatment options for haemorrhoids

A

Office procedures

  • Rubber band ligation
  • Sclerotherapy
  • Infra-red coagulation

In-patient:

  • Surgical hemorrhoidectomy
  • Stapled haemorrhoidopexy
  • Transanal hemorrhoidal artery devascularization
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14
Q

Indications for surgical hemorrhoidectomy

Complications

A

Indications:

  • Severe hemorrhoids: 3rd or 4th degree
  • Mixed internal and external haemorrhoids
  • Failure of other treatments
  • Patient preference

Complications:

  • Bleeding, pain, infection
  • Urine retention
  • Fecal impaction
  • Anal tags and anal stenosis
  • Incontinence
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15
Q

Rubber band ligation of hemorrhoids

  • Benefits
  • Indications
  • C/I
  • Complications
A

Benefits: Most commonly performed since it is inexpensive, easy to perform and rarely causes serious complications

Indication: Only for internal hemorrhoids, grade I,II and III

C/I:
NOT recommended for Grade IV hemorrhoids
Contraindicated in patients with coagulopathies or patients with cirrhosis and portal hypertension due to the risk of significant delayed hemorrhage

Complications
o Pain (most frequent occurring in 8%)
o Delayed hemorrhage
o Localized infection/ Sepsis
o Urinary retention
o Hemorrhoidal thrombosis
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16
Q

Injection sclerotherapy for haemorrhoids

  • Procedure
  • Indication
A
  • Procedure: Injection of sclerosants such as phenol (5%) in vegetable oil which causes an intense inflammatory reaction destroying redundant submucosal tissue associated with hemorrhoidal prolapse
  • Indication:
    coagulopathies, on antiplatelets or anticoagulants, immunocompromised or with portal hypertension (opposite to rubber band ligation)
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17
Q

Stapled hemorrhoidopexy

  • Procedure
  • Advantages
  • Disadvantages
A

Procedure:
stapling device to remove a ring of rectal mucosa and mucosa with the creation of a mucosal anastomosis above the dentate line
hemorrhoidal tissues are pulled back into anal canal from prolapsed position and the blood supply to hemorrhoids are interrupted

Advantages over hemorrhoidectomy
o Less pain and analgesic, quicker recovery and shorter hospital stay
o Less post-operative bleeding and wound complications
o Higher patient’s satisfaction

Disadvantages over hemorrhoidectomy
o Higher recurrence rate
o Serious complications can occur including rectal perforation, rectovaginal fistula and pelvic sepsis

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18
Q

Transanal hemorrhoidal artery vascularization

Procedure

A
  1. Small ultrasound probe insert into anus to locate vessels of hemorrhoids
  2. Each blood vessel stitched close to block bloodflow to hemorrhoids
  3. Optional hemorrhoidectomy after
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19
Q

Complications of untreated hemorrhoids

A 
Complications of hemorrhoids
 Strangulation and thrombosis
 Gangrene
 Ulceration
 Fibrosis
 Portal pyemia
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20
Q

Fissure-in-ano

  • Definition
  • Typical location
  • Histological changes in chronic fissure
A
  • Definition: Split in anoderm at the dentate line
  • Typical location: 90% at posterior midline
  • Histological changes in chronic fissure: Sentinel pile, hypertrophic papilla, visualize internal sphincter muscles at base of fissure
21
Q

Causes/ Etiologies of Fissure- in- ano

Primary and secondary causes

A 
1. Primary causes
Local trauma to anal canal
• Passage of hard stools
• Prolonged diarrhea
• Vaginal delivery
• Anal sex
  1. Secondary causes
    Inflammatory bowel disease
    • Crohn’s disease
    • Ulcerative colitis

Granulomatous disease
• Extrapulmonary TB
• Sarcoidosis

Malignancy
• Squamous cell anal cancer
• Leukemia

Sexually-transmitted diseases
• HIV infection
• Syphilis
• Chlamydia

22
Q

Pathogenesis of anal fissures

A

Stretching of anal mucosa beyond its normal capacity
• Repeated injury leads to spams of the exposed internal sphincter muscle beneath the tear
• Spasm pulls the edges of fissure apart which impairs healing of wound

Ischemia secondary to reduced perfusion
• Anoderm at posterior midline has less blood flow than other quadrants in anal canal
• Increased anal pressure leads to reduced rate of perfusion

23
Q

Fissure-in-ano

S/S
Typical and atypical features

A

Signs and symptoms:
1. Painful defecation
• Tearing pain with passage of bowel movements
2. Bright rectal bleeding
• Limited to a small amount on toilet paper or surface of stool
3. Perianal pruritus or skin irritation

Typical features:
• Single posterior or anterior fissure without evidence of Crohn’s disease

Atypical features
• Multiple, recurring, non-healing, deep or wide, painless and at off-midline locations
• Suggests secondary causes of anal fissures

24
Q

Ddx fissure-in-ano

A

 Perianal ulcers or sores
 Anorectal fistula
 Solitary rectal ulcer syndrome

25
Q

Physical examination technique for anorectal fissure

How to differentiate acute from chronic fissure

A

Most common location of primary anal fissure is posterior anal midline
Spread buttock to reveal fissure, DO NOT PERFORM RECTAL EXAM OR PROCTOSCOPY

Acute fissure (Pathognomonic feature = Superficial tear)
o Superficial tear
o Fresh laceration resembling a paper cut

Chronic fissure (Pathognomonic feature = Hypertrophied with skin tags or papillae)
o Raised edges exposing white horizontally oriented fibers of the internal anal sphincter muscle fibers at the base of fissure
o Hypertrophied anal papillae at the proximal end of fissure
o Skin tags (sentinel pile) at the distal end of fissure

26
Q

Non-operative/ Medical treatment options for anal fissure

A
  1. Bulk agents and Stool softeners
  2. Warm Sitz Bath
  3. Topical anesthetics: Lidocaine jelly
  4. Reduce internal sphincter pressure: Topical vasodilators
    • Topical nifedipine ointment
    • Topical nitroglycerin ointment
27
Q

Surgical treatment options for fissure-in-ano

A

Indicated in patients who fail 8 weeks of initial medical treatment
 Botulinum toxin type A injection
 Lateral internal sphincterotomy

28
Q

Anorectal abscess

Etiologies

A

Cryptoglandular infection*
• Infection of the anal glands

Other infections
• Inflammatory bowel disease
• Tuberculosis
• Actinomycosis
• Foreign body
- Surgical

Malignancies

29
Q

Describe the progression of cryptoglandular infection into systemic infection

A

 Acute phase manifestation of a collection of purulent material that arises from glandular crypts in anus or rectum
• Anorectal fistula is the chronic phase of suppuration in this perirectal process

 Traverse distally in intersphincteric groove into perianal skin
 Can expand into adjacent tissues including ischiorectal and supralevator space or even progress into generalized systemic infection

30
Q

Anorectal abscess

4 different sites

A 
Different sites of anorectal abscess
 Perianal region (20%)
 Intersphincteric region (18%)
 Ischiorectal region (60%)****
 Supralevator region (2%)
31
Q

Anorectal abscess

Pathogenesis

S/S

Treatment

A

Pathogenesis of an anal abscess
 Originates from an infected anal crypt gland which penetrate the internal sphincter and end in the intersphincteric plane
 Obstruction of anal crypt gland with inspissated debris permits bacterial growth and abscess formation

Signs and symptoms
Pain in anal or rectal area
• Constant pain
• Not necessarily associated with a bowel movement
• Associated with symptoms including fever and malaise
Purulent discharge
Constipation
Urinary difficulties

Tx:
Incision and drainage***
Antibiotics has MINIMAL role
• Except in patients with cellulitis, valvular heart disease, prosthetic heart valves and immunosuppression

32
Q

Differential dx of anorectal abscess

A

 Anorectal fistula
 Internal hemorrhoid
 Presacral epidermoid cyst

33
Q

Fistula-in-ano

Definition
4 classifications

A

Fistula is a communication between 2 epithelial surfaces

Anorectal fistula is the chronic manifestation of the acute perirectal process that forms an anal abscess
• When the abscess ruptures or is drained an epithelialized track can form that connects the abscess in the anus or rectum with the perirectal skin

Classification:

  • Intersphincteric
  • Transphincteric
  • Extrasphincteric
  • Suprasphincteric
34
Q

Classification of anorectal fistulas

Pathogenesis

A

Majority of anorectal fistula originate from an infected anal crypt gland
• Glands penetrate the internal sphincter and end in intersphincteric plane

Anorectal fistula is the connection between two epithelial structures
• Connects the anal abscess from the infected anal crypt glands to the perirectal skin

35
Q

Anorectal fistula

Differentiate simple and complex fistula

A

 Simple fistula
• Minimal involvement of external sphincter
• Park’s classification Type 1 (intersphincteric)
• Park’s classification Type 2 (transsphincteric) involving < 30% of anal sphincter complex

 Complex fistula
• Any fistula involving more than 30% of external sphincter
• Park’s classification Type 3 (suprasphincteric)
• Park’s classification Type 4 (extrasphincteric)
• Fistula with multiple tracts
• Recurrent fistula
• Fistula related to inflammatory bowel disease (IBD), infections, local radiation

36
Q

Causes/ etiologies of anorectal fistula

Ddx

A 
Anorectal abscesses (most common >90%)
• Often evolves from a spontaneously draining anorectal abscess originating from the crypts of Morgagni (cryptoglandular infection) which are located between two layers of anal sphincter

Other causes:
Crohn’s disease, Lymphogranuloma venereum (Chlamydia trachomatis), Radiation proctitis, Rectal foreign bodies, Actinomycosis

Ddx:
 Anal abscess
 Anal fissure
 Anal ulcers or sores

37
Q

Anorectal fistula

S/S

A

Painful defecation
• Intermittent rectal pain particularly during defecation but also with sitting and activity

Bleeding

Swelling

Purulent drainage - lowers pain
• Intermittent and malodorous perianal drainage

Perianal pruritus

38
Q

Anorectal fistula

Investigations
Indication for imaging

A

Internal and external opening of fistula tract need to be identified

 Anorectal examination
 Anoscopy or sigmoidoscopy

Radiological tests
 Examination under anesthesia (EUA) with Fistula Probe

Imaging modalities:
• Endosonography (EUS)
• CT/ MRI anal canal
• Fistulography

MRI for: complicated high fistula, recurrent fistula, poor anatomy

39
Q

Anorectal fistula

Surgical treatment options
Alternative/ advanced treatment options

A

Simple low fistula - Fistulotomy/ Fistulectomy

Complicated high fistula/ transphincteric fistula with muscle involvement:

  • Setons: Cutting (snug) seton, Draining seton
  • Endorectal advancement flap: Closing off the internal opening of fistula by a mobilized flap
  • Anal fistula plug: ameliorate postoperative incontinence
  • Ligation of intersphincteric fistula tract (LIFT): Secure closure of internal opening and removal of infected cryptoglandular tissues
Others: 
Video-assisted anal fistula treatment (VAAFT)
- FiLaC (Fistula tract laser closure)
- Permacol paste injection 
- Stem cell treatment
40
Q

Pruritis ani

  • S/S
  • Etiologies
  • Tx
A

S/S:
Itchiness in peri-anal region, lead to excoriations and secondary infections

Etiologies:

  • Idiopathic
  • Personal hygiene
  • Diet
  • Dermatological conditions
  • Infections
  • Psychogenic
  • Diarrhea
  • Systemic diseases, drugs
Tx: 
Treat underlying cause
Reassurance 
Skin care: keep perianal skin dry, avoid soap, avoid prolonged topical steroids
Change diet
41
Q

Rectal prolapse

Definition
Cause
Differentiate complete and partial prolapse

A

Rectal prolapse is a pelvic floor disorder. Full thickness protrusion of rectum through anal sphincters

Failure of pelvic floor muscles/ levator ani (puborectalis + pubococcygeus + iliococcygeus muscles)

Extent of rectal prolapse
• Complete rectal prolapse refers to protrusion of all layers of rectum through the anus
• Partial rectal prolapse refers to protrusion of the mucosa only

42
Q

Complications of rectal prolapse

A

Rectral intussusception

Loss of rectal fixation

Redundant sigmoid

Levator ani diastasis

Patulous anal sphincter

Pudendal neuropathy

43
Q

Rectal prolapse

Etiologies

A

Neurological disorders

Parity

Chronic Constipation/ straining/ diarrhea

Childhood factors: Cystic fibrosis, Whooping cough, Developmental abnormalities, Malnutrition

44
Q

Outline risk factors of rectal prolapse

A

Demographics
• Female age > 40

Medical history
• Chronic straining
• Chronic constipation
• Chronic diarrhea
• Pelvic floor dysfunction
• Pelvic floor anatomic defects: Rectocele, Cystocele, Enterocele, Deep cul-de-sac
• Dementia
• Stroke

Surgical history
• Prior pelvic surgery

Obstetrics and gynaecological history
• Multiparity
• Vaginal delivery

45
Q

Rectal prolapse

S/S

A

Fecal Incontinence
Constipation
Protrusion

Pain, Bleeding and mucus/stool discharge

Tenesmus/ Rectal pressure

46
Q

Rectal prolapse

Treatment options for abdominal and perineal repair

A 
Abdominal repair: 
Rectal fixation (suture/ mesh)
Sigmoid resection
Proctectomy 
Combination rectal fixation and sigmoid resection 
Laparoscopic Ventral Mesh Rectopexy

Perineal repair:
Full thickness resection
Mucosal resection with muscular reefing
Anal encirclement

47
Q

Epidermoid carcinoma of anal canal

Risk factors
S/S
Treatment

A

RF:
Anal intercourse
Sexually transmitted diseases
HPV infection

S/S:
Bleeding, pain and anal mass

Tx:
Chemoradiation
Abdominal perineal resection (for residual or recurrent disease)

48
Q

Anal melanoma

  • S/S
  • Prognosis
  • Tx methods
A

S/S: Bleeding, pain, mass
Local invasive and early metastatic presentation

Prognosis: 6-20% post curative Tx

Tx:
Abdominal perineal resection/ wide local excision, Immunotherapy

49
Q

List 3 anal margin cancers

A

SCC
BCC
Kaposis sarcoma

MBBS IV - Junior Clerkship WCS (131 decks)

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