Lecture 37 Anorectal Disorders Flashcards
What is the function of the Anorectum
o Control of defaecation
o Maintenance of continence
Function of the anorectic requires
o Pelvic floor
o Rectal Compliance
o Intact pelvic neurology
Where would an adenoma occur within the anorectum
Above the pectinate line- columnar epithelium
Where would a squamous cell carcinoma occur along the anorectum
Below pectinate - non-keratinising squamous epithelium
What control is the internal sphincter involved with
Smooth muscle
Passive continence
What control is the external sphincter involved with
Voluntary control
Name signs and symptoms fo Haemorrhoids
- Bleeding
- Painless
- Straining
Treatment for Haemorrhoids
o Underlying cause – Constipation o OPD: Rubber band ligation o Surgical HALO- • Haemorrhoid Artery Ligation Anopexy- stapled haemorrhoid
What is a fissure are what are the signs and symptoms of it
- Small, oval shaped tear in skin that lines the opening of the anus
- Pain
- Bleeding
- Glass splinters
How is a fissure treated
• Underlying cause – Constipation o Medical management – GTN/Diltiazem + Lignocaine o Surgical o Botox o Sphincterotomy
What do you have to take into consideration when investigating anal fissures
- PR may not be tolerable
* May be anal cancer
What are the signs and symptoms of perianal abscess
- Excruciating pain
* Signs of sepsis: Tachycardic, temperature, erythema
What are the risk factors of perianal abscess
DM
BMI
Immunosuppression
Trauma
How is perianal abscess treated
o Abx if septic
o Incision and drainage
o Do not go looking for fistulas
Name signs and symptoms of Fistula in ano
- Peri-anal sepsis
- Persisting pus discharge with flare up
- +/- fecal soiling
How is Fistula in ano treated
o Very difficult to treat o Surgical: 50% failure rate Seton – to drain sepsis/mature tract Sphincter preservation techniques Lay open:
What precautions do you have to take when using the lay open method to treat fistula in ano
Low/superficial sphincter are safe to lay open- does not involve the muscle
Involvement of external sphincter-unable to lay it open won’t be able to preserve sphincter
In women it is not recommended because women bear children and pelvic floors are quite slim and child birth makes it slimmer and childbirth makes it slimmer- which can lead to incontinence
What types of fistulas are there
Extrasphincteric Suprasphincteric Transsphincteric Intersphincteric Submucosal
Name the signs and symptoms of anal/rectal cancer
- Painful/painless
- Bleeding
- Indurated
- Red flag signs
How is anal/rectal cancer firstly investigated
•FIT test +ve
Name common routine investigations
- PR examination
- Proctoscopy
- Rigid sigmoidoscopy
- Colonoscopy/flexi sigmoidoscopy
- CT colonoscopy
- CT scan
- MRI rectum
When may a colonic transit study be used
Constipation
When may an anorectal manometry be used
Fistula- measures pressure
When might a defecating proctogram be used
Diagnose Prolapse
When might an MRI be used
Tumour (spread, type of treatment required)
Define Pelvic Floor Dysfunction
• Collection of wide spectrum of symptoms related to defecation
What is the aetiology of pelvic flour dysfunction
- Childbirth related
* All other cases: surgery, abuse, perianal sepsis, LARS
Who does pelvic floor dysfunction mainly affect
o Parous women (bearing off-spring)
Largest group
Symptoms related to pregnancy and childbirth
o All other patients including men, non-parous women
Surgical misadventure
Neurological/connective tissue disorders
Psychological/behavioural issues
What are the broad disorders involved in pelvic floor dysfunction
- Chronic Constipation
- Faecal Incontinence
- Mixed disorders
- Chronic pelvic pain
What are the types of Chronic Constipation
o Dietary (commonest) o Drugs o Organic Hirshsprung EDS o Functional Slow transit (infrequent) Evacuation related (Common) Combination-
Name drugs that may cause constipation
- Aluminium antacids
- Antimuscarinics (e.g. procyclidine, oxybutynin)
- Antidepressants (most commonly tricyclic antidepressants, but others may cause constipation in some individuals)
- Antiepileptics (e.g. carbamazepine, gabapentin, oxcarbazepine, pregabalin, phenytoin) Sedating antihistamines
- Antipsychotics
- Antispasmodics (e.g. dicycloverine, hyoscine)
- Calcium supplements
- Diuretics
- Iron supplements
- Opioids
- Verapamil- CCB
How is chronic constipation assessed
• Exclude sinister pathology o Colonic imaging: Colonoscopy/CT Colon o Baseline bloods: Exclude anaemia o Symtomatic qFIT o Coeliac serology o Faecal Calprotectin as appropriately • Detailed history including dietary to establish type of constipation • Colonic transit studies • Defecating proctogram • May need more investigations to exclude hirshsprung/EDS
When would you treat chronic constipation
- Most patients usually want sinister pathology excluded
- Aggressive dietary management
- Ensure adequate water intake (not just fluids/fizzy drinks)
- Caffeinated coffee
- Biofeedback for learning/relearning toileting habits/posture
- Good trial of conservative measures and life style optimisation
How would you treat chronic constipation
• Start with regular baseline laxatives
• Ensure compliance
• Consider combination therapy
• Second line drugs:
o Proculopride for women only: Failed tx with 2 or more regular laxatives from different classes at highest dose for 6 months and invasive measures considered
o Lubiprostone for all adults: Failed tx with 2 or more regular laxatives from different classes at highest dose for 6 months and invasive measures considered
o Linaclotide: For IBS related constipation
• Other options:
o Peristeen Irrigation system
o Qufora Irrigation
o Antegrade irrigation: ACE (falling out of favour)
• Surgical options for slow transit:
o Sigmoid colectomy: Insufficient evidence
o Subtotal colectomy with end ileostomy
o Subtotal colectomy with ileorectal anastomosis
o Trial with ileostomy prior to undertaking major operatinve intervention
What are the types of Faecal incontinence
o Passive: Internal sphincter defect
o Urge: Rectal pathology, functional
o Mixed: Prolapse
o Overflow: Constipation
How would you assess faecal incontinence
- Detailed history to determine urge/passive/overflow
- Obstetric/surgical history
- ?Trauma/abuse
- Clinical examination
- Anorectal physiology
- Endo-anal USS
- Defaecatory proctogram
What is the purpose of Anal Manometry
o Anal sphincter function: Resting pressure, squeeze increment, Duration of squeeze
o Estimation of functional length of anal canal
o Anorectal pressure responses during abrupt increases in IAB: eg cough
o Changes in anal pressure during defaecation
o Recto-anal inhibitory reflex (RAIR
What is RAIR
o Recto-anal inhibitory reflex (RAIR)is a reflex characterized by a transient involuntary relaxation of the internal anal sphincter in response to distention of the rectum
provides the upper anal canal with the ability to discriminate between flatus and fecal material.
What information does a defecting proctogram provide
o Pelvic floor mobility
o Pathological function of the musculature
o Changes to form and axis of organs (Deformation and morphology)
o Compensated/decompensated function
o Internal hernias (enterocoel)
Can be used with MRI
How is faecal incontinence managed
o Low fibre diet o Loperamide o Pelvic floor exercises o EMG if required o Irrigation o Anal plug
Surgical interventions for faecal incontinence
• Sphincter repair • Correct anatomical defect • Sacral nerve stimulator • Anal bulking agent for passive FI o Permacol o GateKeeper o SphinKeeper
Named mixed disorders
- Rectocoel: Passive loss of stool from being trapped due to incomplete evacuation
- Internal rectal prolapse: Symptoms of obstructive defaecation and FI
Whats the management of mixed disorders
o Improve rectal evacuation using different techniques
o Biofeedback
o Enemas/Loperamide
o Surgical intervention
What simple measures can be put in place for chronic pelvic pain
EUA, pudendal nerve block, regular enemas/suppositories
• Is it positional?
