UGI/CR - Anus and Rectum Flashcards
DDx - child rectal bleed
Constipation /poor diet Anal fissure Juvenile polyp Haemorrhoids IBD NAI Trauma Surgical causes - intussusception, volvulus etc
5 most common causes of infective bloody diarrhoea
Noravirus Rotavirus Camplobacter Shigella salmonella
PS Rectal cancer
Bright red PR bleed
Tenesmus
PR - mass? +/- mucus
PS Anal cancer
Bleeding Pain Changes in bowel habit pruritis ani Masses Stricture
Where is the anal canal from?
Superior aspect of pelbic diaphragm –> anus
What is the internal anal sphincter?
Involuntary sphincter surrounding upper 2/3 anal canal
What is tonic contraction of the internal anal sphincter stimulated by?
Sympathetic fibres from superior rectal/hypogastric plexus
Role of parasympathetic fibres on the internal anal sphincter
Inhibit tonic contraction
Where is the external anal sphincter
Lower 2/3 anal canal
Is the external anal sphincter under voluntary or involuntary control
Voluntary control
Which nn mediates the external anal sphincter?
Inferior rectal nn
S4
What is a haemorrhoids
Disrupted/dilated anal cushions
Where are internal haemorrhoids
Above the dentate line
Where are external haemorrhoids
Below dentate line
Position of haemorrhoids
3,7,11 oclock (when view from lithotomy position)
Why do haemorrhoids arise?
Because of breakdown of SM layer, muscularis mucosae
Aetiology haemorrhoids (3)
Idiopathic
Incr anal tone (e.g. chronic constipation)
Factors –> congestion superior rectal
Factors causing congestion of superior rectal vv (4)
Cardiac failure
Pregnancy
Rectal carcinoma
Any raised IAP
Where does the superior rectal vein drain?
Inferior mesenteric vv
Where does the inferior = middle rectal veins drain?
Cavally
Link between haemorrhoids and anal rectal varices
Anastomoses of anal cushions = portal-caval anastomoses
Anal-rectal varices can co-exist w/ haemorroids in pt w/ portal HTN
Haemorrhoids most commonly arise in abscence of portal HTN
1st degree haemorrhoids
Confined to anal canal
Bleed but don’t prolapse
2nd degree haemorrhoids
Prolapse on defecation
Then reduce spontaneously
3rd degree haemorrhoids
Prolapse outside anal margin on defecation
May be manually reduced
4th degree haemorrhoids
Remain prolapsed outside anal margin at all times
Sx haemorrhoids (5)
Bright red rectal bleed Prolapse Mucous discharge Pruritis ani Painful if piles becomes thrombosed/prolapse
Complications haemorrhoids
Anaemia
Thrombosis
How long does it take thrombosed haemorrhoids to fibrose?
2-3w
Mx of thrombosed haemorrhoids
Conservative
Cold compresses
Opioids
Rest
ix Haemorrhoids (4)
Abdo exam
PR
Proctoscopy/rigid sigmoidoscopy
Colonoscopy/flexi-sigmoidoscopy
Conservative mx haemorrhoids (4)
Consume plenty fl Try not to strain TO analgesia/astringments Bulk forming laxative Anti-inflammatory creams
Non-conservative Mx haemorrhoids
Sclerotherapy
Banding + suction
What is Sclerotherapy
5% phenol + almond oil into each pile
What degree piles can be treated with sclerotherapy
1st/2nd degree only
How often must sclerothearpy be performed?
Monthly
SE sclerothearpy (3)
Pain
Prostatitis
Infection
What degree piles can Banding and suction be used for?
1st - 3rd
Where must Banding + suction be positioned?
Above the dentate line
What degree haemorrhoids is surgery used on
3rd + 4th degree
Types of surgery used for piles Mx
Stapled haemorrhoidopexy
Haemorrhoidal aa ligation (HALO)
What is a perianal haematoma?
Thrombosed external pile
Why is a perianal haematoma painful?
Because it is covered by squamous epithelium + nerves
PS perianal haematoma
Sudden pain + lump on anal verge
Lump is tense, smooth, dark-blue, cherry sized
Mx perianal haematoma in acute phase
Drain under LA
Role of anal sinuses/crypts
Release mucous when compressed by faeces
What are anorectal abscesses usually caused by?
Gut organisms
–> fistula
What conditions are anorectal abscesses associated with? (5)
Chrons Malignancy TB UC DM
PS Anorectal abscess (2)
Painful tender swellings
Constant discharge
Mx Anorectal abscess
Incision + drainage under GA + seton
What is a pilonoidal sinus?
Obstruction of natal cleft hair follicles 6cm above the anus
–> abscess formation w/ foul discharge
Who gets pilonoidal sinus?
Obese males
Mx pilonoidal sinus
Incision of sinus tract
1’ closure
Pre-op Abx
Hygiene + hair removal advice given
Diagnostic tests perianal warts
Operative exploration
Or MRI
Ix if suspect higher up sepsis in peri-anal wart s
EAU
Def fistula in ano
A track that communicates between the skin + anal canal/rectum
Aetiology fistula in ano
TB Chrons Diverticular disease Rectal carcinoma ICC
Ix fistula in ano
Exam under anaesthetic
EAU (Endoanal USS)
MRI
What does Goodsalls rules relate to?
Relates external opening of an anal fistula to the internal opening
Goodsalls rules - Posterior fistulas
Curved track w/ opening in the posterior midline
Goodsalls rules - anterior fistulas
Direct opening into the anal cavity
Mx of superficial low level distula in ano
Laid open to heal by fistulotomy
Mx of high fistula
Injcted w/ fibrin glue/fistula plug + dries up
Use of Seton suture in fistula Mx
Gradually tightened over time to maintain continence
Med Mx recurrent fistulae/Chrons fistula
Metronidazole
What is an Anal fissure
A tear in the sensitive anal canal distal to the dentate line, producing pain on defecation.
Which gender mostly gets anal fissures
Males
RK Anal fissures (5)
Constipation Chrons disease Anorectal infection (TB/HIV) STIs (herpes/syphilis) Haematological malig
Sx Anal fissure (5)
Sharp burning pain, worse on defecation Then dull ache lasting for hrs Assoc constipation pruritis ani bleeding on defecation
o/e anal fissure (3)
Midline longitudinal tear in rectal mucosa Sentinal pile (ext) PR not poss b/c pain + sphincter spasm
Ix Anal fissure
Proctoscopy + Sigmoidoscopy under GA
To exclude other disease
Mx Anal fissure - conservative (3)
Small may heal spont
LLA + LUbe - Sx relief
Fl/fibre/bulk-laxative
Med Mx Anal fissure
0.4% GTN cream (relaxes sphincter)
Botulinum toxin injection (lasts 8w)
Mx of Intractable anal fissure
Lateral sphincterotomy under GA
