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YR3 Gastro > Rectum/anal conditions > Flashcards

Rectum/anal conditions Flashcards

1
Q

What are haemorrhoids?

A

Disrupted and dilated anal cushions

The anus is lined by discontinuous masses of spongy vascular tissue – the anal cushions which contribute to anal closure.

These become enlarged and engorged with a tendency to protrude, bleed or prolapse in the anal canal

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2
Q

How can haemorrhoids be classified?

A

Internal

  • Arise from the superior haemorrhoidal plexus
  • Lie ABOVE the dentate line

External

  • Lie BELOW the dentate line

NOTE: dentate line = a line that divides the upper 2/3 and the lower 1/3 of the anal canal and represents the hindgut-proctodeum junction

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3
Q

How are haemorrhoids graded?

A
  • 1st Degree - haemorrhoids that do NOT prolapse
  • 2nd Degree - prolapse with defecation but reduce spontaneously
  • 3rd Degree - prolapse and require manual reduction
  • 4th Degree - prolapse that CANNOT be reduced
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4
Q

Expain the aetiology of haemorrhoids

A

Caused by disorganisation of the fibromuscular stroma of the anal cushion

Become enlarged and engorged with a tendency to protrude, bleed or prolapse in the anal canal

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5
Q

State some risk factors for haemorrhoids

A

The 3 anal cushions are attached by smooth muscle and elastic tissue, but are prone to displacement and disruption, either singly or together due to:

  • Constipation
  • Prolonged straining
  • Derangement of the internal anal sphincter
  • Pregnancy
  • Portal hypertension
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6
Q

Summarise the epidemiology of haemorrhoids

A

COMMON

Peak age: 45-65 yrs

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7
Q

What are the presenting symptoms of haemorrhoids?

A

Painless rectal bleeding

  • bright bleeding in association with defecation or straining at stool.

Perianal pain

  • Severe in thrombosed external haemorrhoids
  • May be associated with feeling of incomplete evacuation.

Tender palpable perianal mass

  • when there is acute thrombosis

ABSENCE of alarm symptoms (weight loss, anaemia, change in bowel habit, passage of clotted or dark blood, mucus mixed with the stool)

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8
Q

How do you recognise haemorrhoids on physical examination?

A

1st or 2nd degree haemorrhoids are NOT usually visible on external inspection or palpable on DRE unless they are thrombosed

Haemorrhoids are usually visible on proctoscopy- anoscopic examination

colonoscopy/flexible sigmoidoscopy- exclude serious pathology

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9
Q

Ddx for haemorrhoids

A
  • Anal tags
  • Anal fissures
  • Rectal prolapse
  • Polyps
  • Tumours
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10
Q

Generate a management plan for haemorrhoids

A

The main aim of treatment is relief of symptoms.

  • grade 1 haemorrhoids
    • topical corticosteroids
    • diet + lifestyle modifications- high fibre, increased fluid intake
  • grade 2/3 prolapsing internal haemorrhoids
    • rubber band ligation
    • sclerotherapy
  • grade 4 internal, external, or mixed internal and external haemorrhoids
    • Milligan-Morgan haemorrhoidectomy - excision of three haemorrhoidal cushions
    • involves excision of piles +/- litigation of vascular pedicles, as day-case surgery
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11
Q

Identify possible complications of haemorrhoids

A
  • anaemia from continuous/excessive bleeding
  • thrombosis- sudden onset of perianal pain and the appearance of a tender nodule adjacent to the anal canal.
  • incarceration- of prolapsing haemorrhoidal tissue

following surgical haemorrhoidectomy:

  • faecal incontinence
  • pelvic sepsis
  • anal prolapse/stenosis
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12
Q

Summarise the prognosis for patients with haemorrhoids

A
  • Often CHRONIC
  • High rate of recurrence
  • Surgery can provide long-term relief
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13
Q

Define anal fissure

A

Split in the skin of the distal anal canal characterised by pain on defecation and rectal bleeding.

NOTE: 90% of anal fissures are posterior (anterior anal fissures tend to occur after childbirth)

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14
Q

Summarise the epidemiology of anal fissures

A
  • Affects 1/10 people during their life time
  • Both sexes are affected equally
  • Second commonest gastro-intestinal complication of pregnancy after haemorrhoids.
  • Most cases occur 15-40 yrs
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15
Q

What are the risk factors of anal fissure?

A
  • Idiopathic
  • Passage of hard stool- hard stool tears the anal skin from the pectin (at the dentate line)
  • Opiate analgesia- associated with constipation
  • When a hard stool that tears the anal skin is passed, there is not sufficient blood supply to heal the split in the skin because:
    • poor circulation in the posterior midline of the anal canal
    • anal sphincter spasm → constrict inferior rectal artery → ischaemia
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16
Q

What are the presenting symptoms of anal fissure?

A
  • pain on defecation
  • tearing sensation on passing stool- ‘passing glass’
  • fresh blood on stool or on paper
  • anal spasm
  • anal itching (pruritus ani)
17
Q

What is the investigation for anal fissure?

A

clinical diagnosis

18
Q

Generate a management plan for anal fissure

A

Conservative

  • High-fibre diet
  • Softening the stools (laxatives)
  • Good hydration

Medical

  • Lidocaine ointment (local anaesthetic)
  • GTN ointment (relaxes the anal sphincter and promoted healing)
  • Diltiazem (relaxes the anal sphincter and promotes healing)
  • Botulinum toxin injection

Surgical- for refractive patients

  • Lateral partial internal sphincterotomy
  • This relaxes the anal sphincter and promotes healing but it has complications (e.g. anal incontinence)
19
Q

Summarise the prognosis for patients with anal fissure

A

In most people, the fissure will heal within a week or so

Treatment revolves around easing pain by keeping the stools soft and relaxing the anal sphincter to promote healing

20
Q

define rectal prolapse

A

Abnormal protrusion of the full thickness (or only the mucosal layer) of rectum through the anus

21
Q

Explain the risk factors of rectal prolapse

A
  • Straining
  • Abnormal rectal anatomy or physiology (e.g. pelvic floor weakness, poor fixation of rectum to sacrum or reduced anal sphincter pressure)
  • Constipation
  • Causes of increased straining
  • Cystic fibrosis (in children)
  • Previous trauma to the anus/perineum
  • Neurological conditions (e.g. cauda equina syndrome, MS)
22
Q

Summarise the epidemiology of rectal prolapse

A

Relatively COMMON

Most commonly affected: CHILDREN (< 3 yrs) and the ELDERLY

23
Q

Recognise the presenting symptoms of rectal prolapse

A
  • Protruding anal mass
  • Initially associated with defecation
  • May require digital replacement
  • Constipation
  • Faecal incontinence – in 75%
  • PR mucus or bleeding
  • May be an EMERGENCY - irreducible or strangulated prolapse
24
Q

Identify appropriate investigations for rectal prolapse

A

Imaging

  • Proctosigmoidoscopy
  • Defecating proctogram or barium enema

Other

  • Anal sphincter manometry
  • Pudendal nerve studies

Sweat Chloride Test

  • o Performed in children to test for cystic fibrosis
25
Q

What type of cancer is colorectal cancer? where do they most commonly arise?

A

The majority of colorectal cancers are adenocarcinomas derived from epithelial cells.

71% = colon

29% = rectum.

26
Q

How are colorectal cancers classified? State the 5yr survival rate for each stage

A

Duke’s classification

A: limited to muscularis mucosae, 93% 5yr survival rate

B: extension through muscularis mucosae, 77%

C: involvement of regional lymph nodes, 48%

D: distant metastases, 6.6%

27
Q

State some risk factors for colorectal cancer

A
  • increasing age
  • adenomatous polyposis coli mutation
  • polyposis syndromes
  • FHx of colorectal cancer
  • IBD
  • obesity
  • acromegaly
  • limited physical activity
  • western diet: lack of dietary fibre, red meat, alcohol)
  • smoking
28
Q

Explain the pathogenesis of colorectal cancer

A

Complex interaction between environmental and genetic factors.

Epithelial dysplasia → adenomatous polyp → carcinoma

Multi-step process involving the inactivation of a variety of TSG and DNA repair genes, along with simultaneous activation of oncogenes

29
Q

Summarise the epidemiology of colorectal cancer

A
  • 2nd most common cause of cancer death in the West
  • 3rd most common cancer
  • UK: 20,000 deaths per year
  • Average age of diagnosis: 60-65 yrs
  • More common in men
30
Q

Recognise the presenting symptoms of descending colon and rectum cancer

A
  • Change in bowel habit- increased frequency or looser stools
  • Rectal bleeding (blood or mucus mixed with the stools)
  • Tenesmus (due to a space-occupying tumour in the rectum)
  • Palpable rectal mass- 40-80% of patients with rectal cancer
31
Q

Recognise the presenting symptoms of ascending colon cancer

A

Presents later:

  • Anaemia symptoms- 90% RHS patients
  • advanced disease:
    • Weight loss and anorexia
    • abdominal distention
    • palpable lymph nodes
  • Non-specific malaise
  • Lower abdominal pain (rare)
32
Q

What % of colorectal tumours will present as an EMERGENCY?

A

20%

Present with pain + distension due to:

  • large bowel obstruction
  • haemorrhage or peritonitis due to perforation
33
Q

What are the signs of colorectal cancer on physical examination?

A
  • Anaemia, especially in R-sided
  • Abdominal mass
  • If metastatic:
    • Hepatomegaly
    • Ascites (shifting dullness)
  • Low-lying rectal tumours may be palpable on DRE
34
Q

What investigations would you perform for colorectal cancer?

A
  • Bloods:
    • FBC- anaemia
    • LFTs- usually normal
    • Tumour markers
  • Stools
    • FOBT - used as a screening test
  • Endoscopy
    • Sigmoidoscopy
    • Colonoscopy
    • This can be used to biopsy the tumour
  • Double-Contrast Barium Enema
    • May show ‘apple core’ strictures
  • Abdominal ultrasound for hepatic metastases
  • Contrast CT
    • For staging (Duke’s staging)
35
Q
A

YR3 Gastro (12 decks)

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