Rectal and anal disorders Flashcards
What is an anal fissure and what are the symptoms?
1) Anal fissure is a tear or ulcer in the lining of the anal canal, immediately within the anal margin.
2) Bleeding and persistent pain on defecation, and a linear split in the anal mucosa
How is an acute anal fissure managed (present for less than 6 weeks)?
1) Ensuring stools are soft and easily passed. Bulk-forming laxatives are recommended and an osmotic laxative can be considered
2) Short-term topical preparation containing a local anaesthetic or oral analgesic may be offered for prolonged burning pain following defecation.
↳ If inadequate, refer for specialist treatment
How are chronic anal fissure (present for 6 weeks or longer) managed?
1) Chronic anal fissure and associated pain treated with GTN rectal ointment 0.4% or 0.2% [unlicensed].
2) Alternatively topical diltiazem 2% [unl] or nifedipine 0.2-0.5% [unl]. Oral nifedipine and diltiazem may be as effective as topical treatment, but incidence of SE higher and topical preparations are preferred.
3) If no response to first-line patient may be referred to specialist for local injection of botulinum toxin type A
Does the strength of GTN ointment used matter and what side effects can the ointment cause?
1) Strength used does not influence the effectiveness, but increases the incidence of side-effects
2) headache as an adverse effect is quite high-20-30% of patients
what is the benefit of using diltiazem or nifedipine ointment instead of GTN ointment?
They have a lower incidence of adverse effects than topical glyceryl trinitrate
what are the non-drug treatment options for anal fissures?
Surgery is an effective option but is generally reserved for those who do not respond to drug treatment
Haemorrhoids/piles are abnormal swellings of the vascular mucosal anal cushions around the anus. how do internal and external haemorrhoids differ?
1) Internal haemorrhoids arise above the dentate line and are usually painless unless they become strangulated.
2) External haemorrhoids originate below the dentate line and can be itchy or painful.
which individuals are predisposed to developing haemorrhoids?
Women during pregnancy
Outline the non-pharmacological management of haemorrhoids (2)
1) Stools should be kept soft and easy to pass by increasing dietary fibre and fluid intake.
2) Advice about perianal hygiene is helpful to aid healing and reduce irritation and itching.
what drug treatments can be used for haemorrhoids?
1) If constipation present, treat with bulk forming laxative
2) A simple analgesic such as paracetamol for pain
3) Topical combination preparations of local anaesthetics, corticosteroids, astringents, and antiseptics (scheriproct, proctosedyl)
↳Recurrent symptoms, should be referred
Paracetamol is recommended for pain relief as a result of haemorrhoids. Which analgesics should not be used?
1) Opioid analgesics should be avoided as they can cause constipation
2) NSAIDs - Avoided if rectal bleeding is present
Why should topical preparations containing local anesthetics such as lidocaine, benzocaine, cinchocaine only be used for a few days?
1) They may cause sensitisation of the anal skin. Local anaesthetics can be absorbed through the rectal mucosa (systemic side effects possible)
2) Rarely may cause increased irritation
what can long term use of topical corticosteroid preparations used in haemorrhoids cause?
1) Cause ulceration or permanent damage due to thinning of the perianal skin
2) Continuous or excessive use carries a risk of adrenal suppression and systemic corticosteroid effects
Outline the management of haemorrhoids in pregnancy
1) Bulk forming laxatives are not absorbed
2) If treatment with a topical haemorrhoidal preparation is required, a soothing preparation containing simple, soothing products (not local anaesthetics or corticosteroids) can be considered.
↳ No topical haemorrhoidal preparations are licensed for use during pregnancy
What was the MHRA important safety information regarding corticosteroid haemorrhoidal preparations such as Anusol-Hc, Proctosedyl, Scheriproct ect?
Rare risk of central serious chorioretinopathy with local as well as systemic administration
