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CP3 GI Surgery > The Anus > Flashcards

The Anus Flashcards

1
Q

Anal anatomy zones

A

Distal zone-> squamous mucotaneous junction to dentate line

  • non keratinising squamous epithelium
  • very sensitive

Transitional zone-> variable 0.3-2cm

  • transitional epithelium, squamous to columnar
  • anal glands in sub mucosa
  • surrounded by external anal sphincter

Dentate line-> bellow the anal columns

Columns of morgani

  • 6-10 longitudinal folds
  • contain a terminal branch of the superior rectal artery and vein
  • L lateral, R posterior and R anterior most prominent
  • form the anal cushions-> fine control of continence

Columnar mucosal zone

  • relatively insensitive
  • darker reddish blue
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2
Q

Faecal continence

A

Internal sphincter + external sphincter + puborectalis

1) distension of rectum by flatulus/faeces
2) reflexive small relaxation of internal sphincter
3) small amount of contents in to in to anal canal
4) increased pressure in rectum and relaxation of continue muscles
5) defecation
6) increased electrical activity keeps sphincter closed
* if inconvenient sphincters contract and contents of anal canal returns to rectum

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3
Q

Haemorrhoids definition

A

Pathological enlargement of columns of morgani

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4
Q

Haemorrhoids risk factors

A

Familial predisposition
Pregnancy
Constipation
Diarrhoea

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5
Q

Haemorrhoids pathology

A

Initiated by straining to pass hard stool

  • increased intrauterine abdo pressure
  • obstruction of venous return
  • venous plexus becomes enlarged
  • bulging mucosa dragged distally by hard stool
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6
Q

Haemorrhoids classification

A

Internal-> above the dentate line
External-> bellow the dentate line

Grade 1-> never prolapse

Grade 2-> prolapse during defecation and then return spontaneously

Grade 3-> remain prolapsed unless manipulated digitally

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7
Q

Haemorrhoids clinical features

A 
Intermittent 
Days to weeks
Precipitated by constipation 
Red bleeding-on loo role but may also spurt/drip
Pruritis ani
Discomfort on defecation 
Perianal discharge
'Something coming down'

Not palpable unless very large-> visible on protoscopy

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8
Q

Haemorrhoids complications

A 
Prolapse
Thrombosis 
-acute pain with oedematous purple mass-> ice and laxatives
Strangulation 
Anaemia 
Skin tags
Anal polyps
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9
Q

Haemorrhoids management

A 
Increased fluids and fibre
Creams-> treat itch and decrease inflammation/bacteria
Avoid straining
Sclerosant injections
Bonding around neck
Haemorrhoidectomy
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10
Q

Perianal infection causes

A

Infection of anal fissure
STI
Blocked anal glands

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11
Q

Perianal infection pathology

A

1) infection in crypto glandular epithelium
2) internal sphincter breached through crypts of morgani -> inter sphincters space

Downwards spread-> Perianal abcess 80%

Outwards spread-> ischiorectal abcess 15%

Upwards spread-> superiolateral abcess 5%

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12
Q

Perianal infection risk factors

A 
DM
Immunocomprimised 
Anal sex
IBD
Diverticulitis 
Male 20-60y
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13
Q

Perianal infection clinical features

A

3-4 days of pain and difficulty defecating
Pus from rectum
Constipation

Perianal-> painful, red swelling close to anal verge

Ischiorectal-> sepsis, perianal pain, tender over ischiorectal fossa, later mass on DRE

Superolateral-> sepsis, rectal pain, difficulty with micturition

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14
Q

Fistula in ano definition

A

Pus buries through the wall of the anal canal

-> induration on DRE

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15
Q

Perianal infection management

A

Draining, no antibiotics

Send pus for micro-> gut bacteria means fistula

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16
Q

Differentials of rectal bleeding

A 
Haemorrhoids, most common
Anal fissure
Fistula in ano
Diverticular disease
IBD
Colonic polyps 
Colon cancer
17
Q

Perianal haematoma

A

Thrombosis in a subcutaneous vein bellow the transitional zone
Discrete painful swelling
Should resolve

18
Q

Fissure in ano definition

A

Longitudinal tear in the Mucosa and skin of the anal canal, distal to the dentate line
Commonly posterior midline

19
Q

Fissure in ano clinical features

A 
Pain which is worse when defecating and continues after 
Small amount of fresh blood
Sphincter spasm 
Constipation due to fear of pain 
Less painful when chronic

Tear in midline of the posterior margin
Skin tag
Tenderness

20
Q

Fissure in ano management

A

GTN creams-> relax sphincter and increase blood supply
Botox injection
Lateral internal sphincterectomy

21
Q

Anal cancers

A

4% of large bowel cancers
>80% squamous

Causes:

  • HPV 16 and 18
  • intraepithelial neoplasia
  • HIV/immunocomprismised

Symptoms:

  • rectal bleeding
  • perianal pain
  • pruritis
  • incontinence
  • mucous discharge
  • inguinal lymphadenopathy

Management:

  • biopsy and CT
  • MRI
  • small WLE
  • large radio +- chemo

CP3 GI Surgery (8 decks)

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