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Imperial Medicine Year 3 > Perianal Surgery > Flashcards

Perianal Surgery Flashcards

1
Q

What is the anatomy of the rectum?

A
  • 12cm
  • Sacral promontory to levator ani muscles
  • The 3 tenia coli fuse around the rectum to form a
    continuous muscle layer
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2
Q

What is the anatomy of the anal canal?

A
  • 4cm
  • Levator ani muscle to anal verge
  • Upper 2/3 of canal
    Lined by columnar epithelium
    Insensate
    Superior rectal artery and veni
    Internal iliac nodes
- Lower 1/3 canal 
Lined by squamous epithelium 
Sensate 
Middle and inf rectal arteries and veins 
Superficial inguinal nodes

Dentate line = squamomucosal junction
White line = where anal canal becomes true skin.

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3
Q

What are the anal sphincters

A

Internal - thickening of rectal smooth muscle. Involuntary control.

External: Three rings of skeletal muscle

  • Deep
  • Superficial
  • Subcut

Under voluntary control

  • Anorectal ring - Deep segment of external sphincter which is continuous with puboretalis muscle (part of levator ani)
  • Palpable on PR ~5cm from the anus
  • Demarcates junction between anal canal and rectum
  • Must be preserved to maintain continence.
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4
Q

What is a perianal haematoma?

A

Subcut bleeding from a burst venule caused by straining or the passage of hard stool
Also called an external pile.

Presents

  • tender blue lump at the anal margin
  • Pain worsened by defecation or movement

Management

  • Analgesia + Spontaneous resolution
  • Evacuation under LA
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5
Q

What is proctalgia fugax?

A

Young, anxious man
Crampy anorectal pain worse @ night.
Unrelated to defection
Associated with trigeminal neuralgia

Reassurance
GTN cream

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6
Q

Perineal warts?

A

SEen in MSM
Condylomata accuminata
- HPV
- Manage: podophyllin pain, cryo, surgical excision

  • Condylomata lata
    Syphilis
  • Manage: penicillin
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7
Q

What is pruritis ani caused by?

A 
50% idiopathic
Poor hygiene 
Haemorrhoid 
Anal fissure
Anal fistula 
Fungi, worms 
Crohns 
Neoplasia
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8
Q

What are haemorrhoids?

A

Disrupted and dilated anal cushions

Pathophysiology
- Anal cushion: mass of spongy vascular tissue
- Positioned @ 3, 7, 11 O-clock.
Where the three major arteries that feed the vascular plexuses enter the anal canal.

Gravity, straining –> engorgement and enlargement of anal cushions.

Hard stool disrupts connective tissue around cushions

  • Cushions protrude and can be damaged by hard stool
  • -> bright red (capillary bleeding)
  • Haemorrhoid arise above dentate line so not painful.

May ulcerate if gripped by anal sphincter.

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9
Q

Causes of haemorrhoids?

A 
Constipation with prolonged straining 
Venous congestion may contribute 
- Pregnancy 
- Abdominal tumour 
- Portal HTN
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10
Q

Classifications of haemorrhoids?

A

1st degree: never prolapsed
2nd degree: prolapse on defection but spontaneously reduce
3rd: prolapse on defecation but require digital reduction
4th: remain permanently prolapsed.

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11
Q

Symptoms of haemorrhoids?

A

Fresh painles PR bleeding

  • Bright red
  • On paper, on stool, may drip into pan
  • Pruritis ani
  • Lump in perianal area
  • Severe pain = thrombosis
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12
Q

Examination of haemorrhoids?

A
  • Full abdo exam, palpating for masses
  • Inspect perianal area: masses, rectal bleeding
  • DRE: can’t palpate piles unless thrombosed
    rigid sig to identify higher rectal pathology
  • Proctoscopy (also allows Rx)
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13
Q

Differential for haemorrhoids?

A

Perianal haematoma
Fissure
Abscess
Tumour

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14
Q

Management of haemorrhoids?

A

Conservative

  • Increased fibre and fluid intake
  • Stop straining at stool
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15
Q

Medical management of haemorrhoids?

A

Topical preparations

  • Anusol: hydrocortisone
  • topical analgesics

Laxatives: lactulose, Fybogel

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16
Q

Intervention of haemorrhoids?

A

Injection with sclerosant 0 5% phenol in Almond oil
- above dentate line. Can cause impotence and prostatitis.

Barron’s banding –> thrombosis and separation. Superior to injection sclerotherapy.
- SE: bleeding, infection

Cryotherapy
- SE: watery discharge post-procedure

Infra-red coagulation

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17
Q

What are the surgical options for haemorrhoids?

A
  • Excision of piles + ligation of vascular pedicles
  • Lactulose + metronidazole 11 week pre-op
  • Discharge with laxatives post-op
  • SE: bleeding, stenosis.
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18
Q

How do you manage thrombosed piles?

A

Significant pain, examination reveals a purplish oedematous, tender subcut perianal mass.

If patient presents within 72hrs then referral should be considered for excision.

  • Analgesia
  • Ice-packs
  • Stool softener
  • Bed rest with elevated foot of bed
  • Pain usually resolves in 2-3 weeks
  • Haemorrhoidectomy is not usually necessary.
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19
Q

What is an anal fissure?

A

Tear of squamous epithelial lining in lower anal canal

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20
Q

Causes of anal fissure?

A

Mostly trauma 2ndry to passage of hard stool

  • associated with constipation
  • Spasm of internal anal sphincter contributes to pain and –> ischaemia + poor healing.
  • Commoner in women
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21
Q

Rare causes of anal tissue?

A

Multiple + lateral fissures
- Crohns
- Herpes
Anal Ca

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22
Q

Presentation of anal fissure?

A

Intense anal pain

  • Especially on defecation
  • may prevent pt from passing stools
  • Fresh rectal bleeding
    On paper mostly.
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23
Q

Examination of anal fissure?

A

PR often impossible
Midline ulcer is seen
- Usually posterior @ 6 O’clock
- may be anterior

May be mucosal tag –> Sentinel pile (usually posterior @ 6 oclock)

Groin LNs suggest complicating factor: e.g HIV.

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24
Q

Management of anal fissure?

A

If fissure recurrent, chronic or difficult to manage the patient required EUA.

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25
Q

Conservative management of anal fissure?

A

Soaks in warm bath
Toileting advice
Dietary advice: increased fibre and fluids

26
Q

Medical management of anal fissure?

A

Laxatives: lactulose + fybgel
Topical –> resolution in 75%
- Lignocaine

For chronic anal fissure (>6 weeks)

  • GTN
  • Diltiazem

if topical GTN is not effective after 8 week refer to consider surgery or
Botulinum injection

27
Q

Surgical management of anal fissure?

A

Division of internal anal sphincter @ 3 o’clock
Pre-op anorectal US + mannometry

= Sphincterotomy

Complications

  • Minor faecal/flatus incontinence
  • Perianal abscess
28
Q

What is a fistula in ano?

A
  • Abnormal connection between ano-rectal canal and skin.
29
Q

What is the pathogenesis of fistula in ano?

A

Occur 2ndry to perianal sepsis

  • Blockage of intramuscular glands –> abscess
  • Abscess discharges to form

Associated with

  • Crohns
  • Diverticular disease
  • Rectal Ca
  • Immunosuppression
30
Q

Classifications of fistula in ano?

A

high: cross sphincter muscles above dentate line
Low: Don’t cross sphincter muscles above dentate line

31
Q

What is Goodsall’s rule?

A

Determins path of fistula tract

  • Fistula anterior to anus tracks in a straight line.
  • Fistula postioer to anus will always have internal opening at the 6 o-clock position –> curved trck.
32
Q

Presentation of fistula?

A

Persistent anal discharge

Perianal pain or discomfort

33
Q

Examination of fistula?

A

May visualise external opening: may be pus

Induration around the fistula on DRE

Proctoscopy may reveal internal opening.

34
Q

Investigations of fistula?

A

MRI

Endoanal US

35
Q

Management of fistula?

A

Extent of fistula must first be delineated by probing fistula EUA?

36
Q

LOw fistula?

A

Fistulotomy and excision

- Laid open to heal by 2nd intention.

37
Q

High fistula ?

A
  • Fistulotomy could damage the anorectal ring
  • Suture - a seton - passed through fistula and gradually tightened over months.
  • Stimulates fibrosis of tract
  • Scar tissue hold sphincter together.
38
Q

What is peri-anal sepsis/Abscess?

A

Anal gland blockage –> infection –> abscess
E.g coli, bacterioids. Staph A

May develop from skin infections
- E.g sebaceous gland or hair follicle

39
Q

Associations of anal absces?

A 
Perianal: 45% 
- Discrete local red swelling close to anal verge
- Ischiorectal: <30% 
Systemic upset 
Extermely painful on DRe
  • Interspincteric/intermuscular: >20%
  • Pelvirectal/supralevator: ~5%
    Systemic upset
    Bladder irritation

Diabetes/malignancy associated.

40
Q

Presentation + examination of anal abscess?

A

Throbbing perianal pain
- Worse on sitting

Occassionally a purulent anal discharge

Spiking fever/temperature

Perianal mass or cellulitic area
Fluctuant mass on PR
Septic signs, fever, tachycardia

41
Q

Management of perianal abscess /

A

ABx may suffice if management instigated v.early in course.

Most cases require EUA with I+D. (incision and draining)

  • Wound packed
  • heals by 2nd intention
  • Daily dressing for 7-10 days.

Look for an anal fistula which complicates ~30% of abscess.

42
Q

What is a pilonidal sinus?

A

Definition -

  • Pilonidal - nest of hair
  • Sinus: blind ending tract, lined by epithelial or granulation tissue. Opens an epithelial surface.
43
Q

How does a pilonidal sinus form?

A

Hair works its way benath skin –> foreigh body reaction –> formation of abscess.

Usually occur in the natal cleft.

44
Q

Risk factors of pilonidal sinus

A

M>F = 4:1
- geo: Mediterranean, middle east, asian

  • Often overweight with poor personal hygiene
  • Occupations with lots of sitting: e,g truck drivers
45
Q

Presentation of pilonidal sinus?

A

Persistent discharge or purulent or clear fluid

Recurrent pain

Abscesses

46
Q

Management of pilonidal sinus?

A

Conservative

  • Hygiene advice
  • Shave/remove hair from affected areas
Surgical 
- Incision + drainage of abscesses
- Elective sinus excision 
Methylene blue to outline tract 
Recurrence in 4-15%.
47
Q

Anal carcinoma?

A

Uncommon: 250-300 cases yr in the UK.

Pathology
- 80% - SCC (also melanoms, adenocarcinomas)

Anal margin tumours

  • Well differentiated keratinising lesions
  • Commoner in men
  • Good prognosis

Anal canal tumour

  • Arise above dentate line
  • Poorly differentiated, non-keratinising
  • Commoner in women
  • Poor prognosis

Spread

  • Above dentate line –> Internal iliac nodes
  • Below dentate line –> inguinal nodes
48
Q

Aetiology of anal carcinoma?

A 
HPV (16,18, 31, 33) is important factor 
- Most important. 
- Increased incidence in MSM
 Increased incidence if perianal warts.
- Smoking is also a risk factor
- IMmunosupression
49
Q

Presentation of anal carcinoma?

A
  • Perianal pain and bleeding
  • Pruritus ani
  • Faecal incontinence
  • -> 70% have sphincter involvement @ presentation
  • May have rectovaginal fistula

Palpable lesion in only 25%
± palpable inguinal nodes

50
Q

Investigations for anal carcinoma?

A

Low Hb
Endoanal US
Rectal EUA + biopsy
CT/MRI: assess pelvic spread

51
Q

Management of anal carcinoma?

A

Chemoradiotherapy: Most pts
- 50% 5yrs

Surgery
- Reserved for:
Tumours that fail to respond to radiotherapy

GI obstruction

Small anal margin tumours without sphincter involvement.

52
Q

What is rectal prolapse?

A

Protrusion of rectal tissue through anal canal

53
Q

Type 1 prolapse?

A

Mucosal prolapse

  • Partial prolapse of redundant mucosa
  • Common in children esp with CF.
54
Q

Type 2 prolapse?

A

Full thickness

  • Commoner compared to Type 1
  • Usually elderly females with poor O+G History
55
Q

Presentation of rectal prolapse?

A
  • Mass extrudes from rectum on defection
  • May reduce spontaneously or require manual reduction
  • May become oedematous and ulcerated –> pain and bleeding
  • Faecal soiling
  • Associated with vaginal prolapse and urinary incontinence
56
Q

Examination of rectal prolapse?

A

Visible prolapse: brought out on straining
± excoriation and ulceration
Decreased sphincter tone on PR
Associated with uterovaginal prolapse

57
Q

Investigations or rectal prolapse?

A

Sigmoidoscopy to exclude proximal lesions
Anal manometry
Endoanal US
MRI

58
Q

Management of prolapse?

A

Partial prolapse
- Phenol injection
- Rubber band ligation
Surgery: delorme’s Procedure

Complete Prolapse
- conservative
PElvic floor exercises
Stool softeners

59
Q

Surgery of prolapse?

A

Abdominal approach: rectopexy

  • Lap or open
  • Mobilise rectum fixed to sacrum with mesh

Perineal approach
- Delorme’s procedure
Resect mucosa and suture the two mucosal boundaries
- Almeirs procedure resects the colon via the perineal route.

60
Q

Rectal intussceception

A

Typically presents with with symptoms of obstructed defecation.

Pathology is best demonstrated by defecating proctogram rather than barium enema.

61
Q

Solitary rectal ulcer?

A

Associated with chronic straining and constipation

Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle.

Diagnostic work up should include endoscopy and probably defacting proctogram.

Imperial Medicine Year 3 (35 decks)

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