JC62 (Surgery) - Anorectal diseases Flashcards

Question

Physical examination technique for anorectal fissure How to differentiate acute from chronic fissure

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

Cryptoglandular infection* • Infection of the anal glands ``` Other infections • Inflammatory bowel disease • Tuberculosis • Actinomycosis • Foreign body - Surgical ``` Malignancies

Answer 5

 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

Answer 6

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

Answer 7

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

Answer 8

 Anorectal fistula  Internal hemorrhoid  Presacral epidermoid cyst

Answer 9

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

Answer 10

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

Answer 11

 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

Answer 12

``` 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

Answer 13

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

Answer 14

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

Answer 15

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 ```

Answer 16

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 ```

Answer 17

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

Answer 18

Rectral intussusception Loss of rectal fixation Redundant sigmoid Levator ani diastasis Patulous anal sphincter Pudendal neuropathy

Answer 19

Neurological disorders Parity Chronic Constipation/ straining/ diarrhea Childhood factors: Cystic fibrosis, Whooping cough, Developmental abnormalities, Malnutrition

Answer 20

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

Answer 21

Fecal Incontinence Constipation Protrusion Pain, Bleeding and mucus/stool discharge Tenesmus/ Rectal pressure

Answer 22

``` 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

Answer 23

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)

Answer 24

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

Answer 25

SCC BCC Kaposis sarcoma