Perianal disorders Flashcards by Neil Srivastava

Define haemorrhoids

Disrupted and dilated anal cushions (masses of spongy vascular tissue due to swollen veins around the anus

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What are anal cushions

Spongy vascular tissue which lines the anus (discontinuous masses)

These contribute to anal closure

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Main causes of Haemorrhoids

Constipation with prolonged strain
Diarrhoea
Effects of gravity due to posture
Congestion from pelvic tumour, pregnancy, portal hypertension
Anal Intercourse

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What structures attach to the anal cushions

Smooth muscle and elastic tissue

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Why is blood in stools of haemorrhoids bright red

They come from capillaries

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Why are anal cushions very vulnerable to trauma

Bleed readily from the capillaries of the underlying lamina propria

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What is the dentate line

Squamomucosal junction

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Are sensory fibres found above the dentate line

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How does that effect pain in haemorrhoids

Piles are NOT painful

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When are piles painful

If they thrombus when they protrude and are gripped by anal sphincter blocking venous return

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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

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Where do internal haemorrhoids originate from

Above the dentate line

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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

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Where do external haemorrhoids originate from

Below the dentate line

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Why are external haemorrhoids painful

There is sensory nerve endings below dentate line

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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

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Differential diagnosis of haemorrhoids

Perinanal haematoma
Anal fissure
Abscess
Tumour

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4 diagnostics for haemorrhoids

AXR
Per rectum exam
Proctoscopy (rectal scope)
Sigmoidoscopy

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Role of AXR in haemorrhoids

Rule out other diseases

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Why do we do per rectal exams in haemorrhoids

Prolapsing piles can be seen

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Can internal haemorrhoids be seen in PR exams

No - not palpable

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What is used to see internal haemorrhoids

Proctoscopy

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1st degree treatment of haemorrhoids

Increase fluid and fibre

2. Analgesic and stool softener

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2nd degree treatment of haemorrhoids

Rubber band ligation

2. Infra-red coagulation

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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

1. 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

1. Perinanal sepsis 2. Abscesses 3. Crohn's 4. TB 5. Diverticular disease 6. Rectal carcinoma

Clinical presentation of anal fistulas

1. Pain 2. Discharge 3. Pruritus ani (itchy bottom) 4. Systemic abscess if it becomes infected

How are anal fistulas diagnosed

1. MRI | 2. Endoanal ultrasound

Why is an MRI done for anal fistulas

1. 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

1. Surgical (Fistulotomy ande cisión) | 2. Drian abscess with antibiotics if infected

What is an anal fissure

1. 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

1. Extreme pain on defecation | 2. Bleeding

How are anal fissures diagnosed

1. History alone 2. Confirmed on perianal inspection 3. rectal examination is often not possible due to pain and sphincter spasm

How is anal fissure treated

1. Increase fibre and fluids to soften stool 2. LIDOCAINE OINTMENT + GTN OINTMENT OR DILITIAZEM BOTOX (2ND LINE) SURGERY

Clinical presentation of perianal abscess

1. Painful swellings 2. Tender 3. Discharge

What sexuality are perinala abscesses commonly found in

2/3 times more common in gay sex

How are perianal abscesses diagnosed

1. MRI | 2. Endoanal ultrasound

How are perianal abscesses treated

1. Surgical excision | 2. Drainage with antibiotics

What are pilonidal sinuses

1. 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

1. OBESE caucasians 2. Large amount of body hair 3. Sedentary jobs 4. Occupation involving sitting or driving 5. Family History

Clinical presentation of pilondial sinuses

Acute: 1. Painful swelling over days 2. Pus filled and foul smell 3. 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

1. Surgery (excision of sinus tract as primary closure and pus drainage + pre-op antibiotics) 2. 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

1. Stress 2. Food 3. Gastroenteritis 4. Menstruation

What is gastroenteritis

Infectious diarrhoea

Main causes of IBS

1. Depression, anxiety 2. Psychological stress and trauma 3. GI infection 4. Sexual, physical or verbal abuse 4. Eating disorders

What are the three types of IBS

1. IBS - C (constipation) 2. IBS - D (Diarrhoea) 3. IBS - M (constipation and diarrhoea)

Risk factors for IBS

1. Female 2. Long diarrhoea 3. High hypo-chrondrial anxiety and neurotic score at time of initial illness