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Perianal surgery Flashcards

1
Q

key anatomy of rectum?

A

extends from the inferior end of the sigmoid colon along the anterior surface of the sacrum to levator ani muscle

12cm

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2
Q

key anatomy of anal canal?

A

4 cm

levator ani muscle to anal verge

upper 2/3 of canal: lined by columnar epithelium, insensate

lower 1/3 of canal: squamous epithelium, sensate

dentate late = squamomucosal junction

white line = where anal canal becomes true skin

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3
Q

differences between upper 2/3 of anal canal and lower 1/3?

A

upper 2/3:

lined by columnar epithelium

insensate

superior rectal artery and vein

internal iliac nodes

lower 1/3:

squamous epithelium

sensate

middle and inf rectal artery and veins

superficial inguinal nodes

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4
Q

what is the dentate line?

A

squamomucosal junction of the anal canal

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5
Q

internal vs external anal sphincters?

A

internal:

thickening of rectal Smooth muscle -> involuntary control

External:

three rings of skeletal muscle (deep, superficial, subcut) -> voluntary control

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6
Q

what is the anorectal ring?

A

deep segment of external sphincter which is continuous w puboretalis muscle (part of levator ani)

demarcates junction between anal canal and rectum

palpable on PR 5 cm from anus

must be preserved to maintain continence

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7
Q

what is a perianal haematoma?

A

subcut bleeding from a burst venule caused by straining/ passage of hard stool

aka external pile (misnomer)

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8
Q

presentation of perianal haematoma?

A

tender blue lump at anal margin

pain worsened by defecation or movement

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9
Q

mx of perianal haematoma?

A

analgesia + spontaneous resolution

or

evacuation under LA

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10
Q

what is proctalgia fugax?

A

anal pain w no specific cause

usually young, anxious men

crampy anorectal pain, worse at night

unrelated to defecation

assoc w trigeminal neuralgia

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11
Q

what is proctalgia fugax assoc w?

A

trigeminal neuralgia

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12
Q

mx of proctalgia fugax?

A

reassurance

GTN cream

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13
Q

perineal warts assoc w?

A

MSM

may be due to HPV

or Syphilis (condylomata lata)

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14
Q

mx of perineal warts due to syphilis?

A

penicillin

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15
Q

mx of perineal warts due to HPV?

A

podophyllin pain

cryo

surgical excision

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16
Q

definition of haemorrhoids?

A

Dilated (enlarged) veins in the walls of the anus

(dilated and disrupted anal cushions)

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17
Q

where are haemorrhoids usually positioned?

A

3, 7 and 11 o clock

(due to this being where the 3 major arteries that feed the vascular plexuses enter the anal canal)

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18
Q

pathophysiology of haemorrhoids?

A

gravity, straining -> engorgement and enlargement of anal cushions

cushions protrude, may be damaged by hard stool-> bright red bleeding

haemorrhoids arise above dentate line -> not painful

may be gripped by anal sphincter -> thrombosis

(strangulated piles are acutely painful, may ulcerate or infarct)

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19
Q

causes of haemorrhoids?

A

constipation w prolonged straining

venous congestion: pregnancy, abdo tumour, portal HTN

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20
Q

classification of haemorrhoids?

A

1st degree: never prolapse

2nd: prolapse on defecation but spontaneously reduce
3rd: prolapse on defecation but require digital reduction
4th: remain permanently prolapsed

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21
Q

features of haemorrhoids?

A

fresh painless PR bleed

pruritus ani

lump in perianal area

severe pain = thrombosis

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22
Q

mx of haemorrhoids?

A

conservative:

increase fibre and fluid intake

reduce straining

medical:

topical analgesics, hydrocortisone

laxatives: lactulose, fybogel

interventional:

Banding, cryotherapy, infra red coagulation, injection w sclerosant

Surgical: haemorrhoidectomy

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23
Q

mx of thrombosed haemorrhoids?

A

analgesia

ice packs

stool softeners

bed rest w elevated foot of bed

pain usually resolves in 2-3 wks

haemorrhoidectomy usually not necessary

24
Q

definition of anal fissure?

A

tear of squamous epithelial lining in lower anal canal

25
causes of anal fissure?
constipation crohns anal ca herpes
26
features of anal fissure?
intense anal pain esp on defecation fresh rectal bleeding (on paper)
27
examination of anal fissure?
PR often impossible midline ulcer is seen may have mucosal tag - sentinel pile groin LNs suggest complicating factor e.g. HIV
28
mx of anal fissures?
if fissure recurrent, chronic or difficult to tx, pt needs examination under anaesthesia **conservative**: soaks in warm bath, toileting advice, dietary advice **medical:** laxatives, topical analgesia (Lignocaine, GTN, diltiazem), botulinum injection **surgical: lateral partial sphincterotomy** division of int anal sphincter @ 3 o clock pre-op anorectal US and mannometry
29
definition of fistula?
abnormal connection between 2 epithelial surfaces
30
definition of fistula in ano?
abnormal connection between anorectal canal and the skin
31
risk factors for anal fistula?
perianal abscess crohns diverticular disease rectal ca immunosuppression
32
classification of fistula in ano?
high: cross sphincter muscles above dentate line low: dont cross sphincter muscles above dentate line
33
presentation of anal fistula?
persistent anal discharge perianal pain or discomfort
34
ix of anal fistula?
MRI endoanal US
35
mx of anal fistula?
extent of fistula must be first delineated by probing fistula @ EUA Low fistula: fistulotomy and excision - laid open to heal by secondary intention high fistula: fistulotomy could damage anorectal ring suture (a Seton) passed through fistula and gradually tightened over months -\> stimulates fibrosis of tract + scar tissue holds sphincter tgt
36
mx of perianal abscess?
abx most require EUA w Incision and drainage - wound packed, healing by secondary intention look for anal fistula which complicates 30% of abscesses
37
examination findings of perianal abscess?
septic signs: fever, tachycardia fluctuant mass on PR perianal mass or cellulitic area
38
presentation of perianal abscess?
throbbing perianal pain worse on sitting occasionally a purulent anal discharge
39
definition of pilonidal sinus?
pilonidal: 'nest of hair' sinus: blind ending tract, lined by epithelial or granulation tissue, which opens into an epithelial surface
40
pathophysiology of pilonidal sinus?
hair works its way beneath skin -\> foreign body reaction -\> formation of abscess usually occur in natal cleft
41
risk factors of pilonidal sinus?
Males often overweight w poor personal hygiene occupations w lots of sitting e.g. truck drivers
42
presentation of pilonidal sinus?
recurrent pain persistent discharge of purulent or clear fluid abscesses
43
mx of pilonidal sinus?
conservative: hygiene advice, shave/ remove hair from affected area surgical: incision and drainage of abscesses elective sinus excision
44
most common type of anal ca?
80% SCCs
45
spread of anal ca to which lymph nodes?
above dentate line -\> int iliac nodes below detate line -\> inguinal nodes
46
risk factors of anal ca?
HPV 16, 18, 31, 33 (increased incidence in MSM/ perianal warts)
47
features of anal ca?
perianal pain and bleeding pruritus ani faecal incontinence (70% have sphincter involvement @ presentation) may -\> rectovaginal fistula
48
Ix of anal ca?
low Hb (ACD) endoanal US rectal EUA + biopsy CT/MRI: assess pelvic spread
49
mx of anal ca?
Chemoradiotherapy Surgery: - tumours that fail to respond to radiotx - GI obstruction - small anal margin tumours (good prognosis) w/o sphincter involvement
50
defintion of rectal prolapse?
protrusion of rectal tissue through the anal canal
51
classification of rectal prolapse?
type 1: mucosal prolapse - partial prolapse - commoner in childern esp w CF - essentially large piles -\> same mx type 2: full thickness prolapse - more common - usually elderly females w poor O&G hx
52
Examination findings of anal prolapse?
visible prolapse +/- excoriation and ulceration decreased sphincter tone on PR assoc uterovaginal prolapse
53
ix of anal prolapse?
sigmoidoscopy to exclude proximal lesions anal manometry endoanal US MRI
54
mx of partial anal prolapse
phenol injection rubber band ligation surgery: delormes procedure
55
mx of complete anal prolapse?
conservative: pelvic floor exercises, stool softeners surgery: Abdo approach - Rectopexy (mobilised rectum fixed to sacrum w mesh) perineal approach - Delorme's procedure (resect mucosa and suture the two mucosal boundaries)

Surgery (17 decks)

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