Perianal disorders Flashcards
Define haemorrhoids
Disrupted and dilated anal cushions (masses of spongy vascular tissue due to swollen veins around the anus
What are anal cushions
Spongy vascular tissue which lines the anus (discontinuous masses)
These contribute to anal closure
Main causes of Haemorrhoids
- Constipation with prolonged strain
- Diarrhoea
- Effects of gravity due to posture
- Congestion from pelvic tumour, pregnancy, portal hypertension
- Anal Intercourse
What structures attach to the anal cushions
- Smooth muscle and elastic tissue
Why is blood in stools of haemorrhoids bright red
They come from capillaries
Why are anal cushions very vulnerable to trauma
Bleed readily from the capillaries of the underlying lamina propria
What is the dentate line
Squamomucosal junction
Are sensory fibres found above the dentate line
No
How does that effect pain in haemorrhoids
Piles are NOT painful
When are piles painful
If they thrombus when they protrude and are gripped by anal sphincter blocking venous return
Describe the positive feedback-like mechanism of haemorrhoids
- Vicious cycle:
The vascular cushions protrude through tight annus -> become more congested and hypertrophy -> protrude again more readily
These protrusions may strangulate
Where do internal haemorrhoids originate from
Above the dentate line
What are the four degrees of internal haemorrhoids
1st - Remain in rectum
2nd - prolapse through anus on defection but spontaneously reduce
3rd - prolapse but can be reduced manually
4th - remain persistently prolapsed
Where do external haemorrhoids originate from
Below the dentate line
Why are external haemorrhoids painful
There is sensory nerve endings below dentate line
Clinical presentation of haemorrhoids
- Bright red, rectal bleeding that coats stools
- Mucus discharge or pruritus ani (itchy bottom)
- Severe anaemia
- Weight loss + change in bowel habit should prompt thoughts of pathology
Differential diagnosis of haemorrhoids
- Perinanal haematoma
- Anal fissure
- Abscess
- Tumour
4 diagnostics for haemorrhoids
- AXR
- Per rectum exam
- Proctoscopy (rectal scope)
- Sigmoidoscopy
Role of AXR in haemorrhoids
Rule out other diseases
Why do we do per rectal exams in haemorrhoids
Prolapsing piles can be seen
Can internal haemorrhoids be seen in PR exams
No - not palpable
What is used to see internal haemorrhoids
Proctoscopy
1st degree treatment of haemorrhoids
- Increase fluid and fibre
2. Analgesic and stool softener
2nd degree treatment of haemorrhoids
- Rubber band ligation
2. Infra-red coagulation
What is rubber band ligation
CHEAP
band around haemorrhoid to stop blood flow
Causes haemorrhoid to die
Sid-effects to rubber band ligation
Bleeding
Infection
Pain
What is infra-red coalition
Locally coagulates vessels and tethers mucosa to subcutaneous tissue
What is final line of treatment for haemorrhoids
Surgery
Excision haemmorhoidectomy (excision of piles) Stupid haemorrhoidpexy
How are prolapsed piles and thromboses piles treated
Analgesia
Ice packs
stool softeners
When does pain from prolapsed or thromboses piles stop
2-3 weeks
What is an anal fistula
- An abnormal connection between the epithelialise surface of the anal canal and skin (a track that communicates between skin and anal canal)
Main causes of anal fistula
- Perinanal sepsis
- Abscesses
- Crohn’s
- TB
- Diverticular disease
- Rectal carcinoma
Clinical presentation of anal fistulas
- Pain
- Discharge
- Pruritus ani (itchy bottom)
- Systemic abscess if it becomes infected
How are anal fistulas diagnosed
- MRI
2. Endoanal ultrasound
Why is an MRI done for anal fistulas
- Exclude sepsis
2. Detect associated conditions
Why is an endoanal ultrasound done for anal fistulas
Determines tracks location and underlying cause
What causes discharge from anal fistulas
Blockage of deep intramuscular gland ducts causes formation of abscesses -> discharges
How are anal fistulas treated
- Surgical (Fistulotomy ande cisión)
2. Drian abscess with antibiotics if infected
What is an anal fissure
- Painful tear in sensitive skin-lined lower anal canal, distal to the dentate line resulting in pain on defecation
Posterior or anterior - most common anal fissure
Posterior
What gender do anal fissure most occur in
Females
What conditions can cause anal fissures
Crohn’s
Ulcerative colitis
Main causes of anal fissures
HARD FAECES
Spasms may constrict inferior rectal artery = ischaemia which makes healing difficult
Syphilis
Herpes
Trauma
Anal cancer
Clinical presentation of anal fissures
- Extreme pain on defecation
2. Bleeding
How are anal fissures diagnosed
- History alone
- Confirmed on perianal inspection
- rectal examination is often not possible due to pain and sphincter spasm
How is anal fissure treated
- Increase fibre and fluids to soften stool
- LIDOCAINE OINTMENT + GTN OINTMENT OR DILITIAZEM
BOTOX (2ND LINE)
SURGERY
Clinical presentation of perianal abscess
- Painful swellings
- Tender
- Discharge
What sexuality are perinala abscesses commonly found in
2/3 times more common in gay sex
How are perianal abscesses diagnosed
- MRI
2. Endoanal ultrasound
How are perianal abscesses treated
- Surgical excision
2. Drainage with antibiotics
What are pilonidal sinuses
- Hair follicles get stuck under the skin in the natal cleft (butt crack) resulting in irritation and inflammation leading to small tracts that get infected
What gender are pilondial sinuses common in
Males
Risk factors for pilondial sinuses
- OBESE caucasians
- Large amount of body hair
- Sedentary jobs
- Occupation involving sitting or driving
- Family History
Clinical presentation of pilondial sinuses
Acute:
- Painful swelling over days
- Pus filled and foul smell
- Systemic signs of infection
Chronic:
4 in 10 have repeated recurrent pilondial sinuses
Infection never clears completely
How are pilondial sinuses diagnosed
Clinical exmianition
How are pilonidal sinuses treated
- Surgery (excision of sinus tract as primary closure and pus drainage + pre-op antibiotics)
- Hygiene and hair removal advice
What is irritable bowel syndrome
A mixed group of abdo symptoms in which no organic cause can be found
What age does IBS arise in
Under 40
What gender does IBS effect
Females
What exacerbates symptoms of IBS
- Stress
- Food
- Gastroenteritis
- Menstruation
What is gastroenteritis
Infectious diarrhoea
Main causes of IBS
- Depression, anxiety
- Psychological stress and trauma
- GI infection
- Sexual, physical or verbal abuse
- Eating disorders
What are the three types of IBS
- IBS - C (constipation)
- IBS - D (Diarrhoea)
- IBS - M (constipation and diarrhoea)
Risk factors for IBS
- Female
- Long diarrhoea
- High hypo-chrondrial anxiety and neurotic score at time of initial illness
