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Flashcards in Anal disorders Deck (47):
1

Define haemorrhoids

Abnormal vascular dilatation of anal mucosal cushions

2

How are haemorrhoids classified?

External or internal depending on origin in relation to the dentate line (transition between upper and lower anal canal).

3

Define external haemorrhoids (3)

Originate below dentate line
Covered by modified squamous epithelium (anoderm)
Richly innervated with pain fibres ➔ itchy and painful

4

Define internal haemorrhoids

Originate above dentate line
Covered by columnar epithelium
No pain fibres ➔ not sensitive to touch, temperature, or pain (unless strangulated)

5

What and where is the dentate line?

The transition between the upper and lower anal canal. Located 2cm from the anal verge.

6

Outline grading of internal haemorrhoids

I. project into lumen of anal canal but does not prolapse

II. prolapse on straining but reduce spontaneously when straining stops

III. prolapse on straining and requires manual reduction

IV. prolapsed and incarcerated and cannot be reduced

7

List 3 risk factors for haemorrhoids

Constipation
Straining while trying to pass stools
Increasing age
Heavy lifting
Chronic cough
Pregnancy, childbirth
Obesity

8

Name 3 complications of haemorrhoids

Ulceration
Skin tags
Maceration of perianal skin (softening and breakdown of skin)
Ischaemia
Thrombosis
Gangrene

Rare: perianal sepsis, anaemia

9

Describe the presentation of haemorrhoids

Bright red, painless rectal bleeding (not mixed with faeces)
Discomfort
Pruritus ani
Tenesmus

Pain if Grade IV internal haemorrhoid or thromboses external haemorrhoid

10

How are haemorrhoids investigated?

Proctoscopy
Sigmoidoscopy: used if sinister symptoms are present or elderly

11

Outline the non-pharmacological management of haemorrhoids

Healthy, high fibre diet
Increased fluid intake
Minimising straining
Good anal hygiene: aids healing, reduces irritation

12

Outline the pharmacological management of haemorrhoids

Simple analgesia e.g. paracetamol
Consider topical analgesia
-avoid NSAIDs if rectal bleeding present
Faecal softeners (decusate sodium and glycerol suppositories)
Laxative: osmotic movicol, or bulk fibrogel

13

Outline the secondary care management of haemorrhoids

Band ligation
Injection sclerotherapy

Haemorrhoidectomy
Haemorrhoidal artery ligation (HALO)

14

Define anal fissure

A tear or ulcer in the lining of the anal cannel, immediately within the anal margin

15

What is the commonest age group affected by anal fissures?

15-40yrs

16

Describe the presentation of anal fissure

Anal pain with defecation +/- bright red rectal bleeding
Anal spasm

17

Differentiate between acute and chronic anal fissures

Acute (<6wk) are superficial with well-demarcated edges

Chronic (6+wk) are wider and deeper with muscle fibres visible in the base. Edges often swollen, and skin tag may be visible.

18

Outline the non-pharmacological management of anal fissures

High fibre diet
Increased fluid intake
Avoid straining
Good anal hygiene

19

Outline the pharmacological management of chronic anal fissures

Analgesia
GTN 0.4% cream - if unhealed after 6-8wk with notable symptomatic improvement
Topical diltiazem 2% cream - if unhealed after 6-8wk, but no notable symptomatic improvement

Botox injection into internal sphincter

20

Outline the surgical intervention for anal fissures

Lateral sphincterotomy - reduces internal sphincter spasms that impaired anal blood supply and reduced fissure healing

Avoid in females due to complications with childbirth and UTIs

21

Describe the presentation of perianal abscess

Gradual onset, constant localised perianal pain
Associated swelling with tenderness +/- discharge
May have associated systemic features: fever, malaise, anorexia

22

Name 2 organisms commonly implicated in perianal abscess

E. coli
Enterococcus spp.
Bacteroides spp.

23

Name 3 risk factors of perianal abscess

Crohn's disease
Diabetes mellitus
Anal fistula
Steroid use
Immunodeficiency

24

Outline the management of perianal abscess

*Surgical emergency*
Incision and drainage

25

Describe the pathophysiology of perianal abscess and subsequent fistula

Crypts of Morgagni that penetrate the internal sphincter become infected. This allows pus to tract to the anal margin and form an abscess.

If the abscess resolves, there is a fistula in this location connecting the anal cavity to the perianal skin.

26

Outline the management of anal fistula

Seton stitch: A thread inserted through the fistula tract and tied outside in a loop. This allows the infection to drain and heal, without damaging the sphincter muscles.

Fistulotomy: Laying open of the fistula to allow healing by secondary intention.

27

Define pilonidal sinus disease

Skin disorder featuring openings in the midline of the natal cleft, that allow loose hair and debris to enter creating an epithelial track (sinus)

28

Name 3 risk factors for pilonidal sinus disease

Male
15-40yr
Caucasian
Hirsutism
Obesity

29

Describe the presentation of pilonidal sinus disease

Asymptomatic, or
Acute: pilonidal abscess
Chronically discharging sinus

30

Name 2 complications of pilonidal sinus disease

Cellulitis
Sepsis
Chronic pain
Altered body image

31

Outline the management of acute pilonidal abscess

Urgent incision and drainage
Analgesia
Advice to reduce recurrence: perianal hygiene, buttock hair removal techniques

32

Outline the primary care management of discharging pilonidal sinus disease

Refer to colorectal or general surgical unit
Analgesia
Antibiotics if cellulitis suspected

33

Outline the surgical management of discharging pilonidal sinus disease

For recurrent abscess or a small sinus ➔ pit picking method (removal of midline pit), excision of superficial abscess scars, drainage of track.

For chronic discharging sinuses ➔ wide excision of sinus tracks + primary closure or leaving wound open to heal by secondary intention. Cover with tissue flap if possible to minimise infection risk.

34

What is the commonest type of anal cancer?

Squamous cell carcinoma (80%)

35

Name 3 types of anal cancer

Squamous cell carcinoma (80%)
Melanoma
Lymphoma
Adenocarcinoma

36

Outline the epidemiology of anal cancer

Uncommon (only 4% of lower GI cancers)
Incidence 1 in 10,000
F>M

37

Which anal cancers are commoner in men?

Anal margin tumours: well differentiates, good prognosis

38

Which anal cancers are commoner in women?

Anal canal tumours: poorly differentiated, worse prognosis

39

Where do anal cancers most commonly metastasise?

Liver
Lungs

40

Name 3 risk factors for anal cancer

Human papilloma virus (HPV): HPV risk increased by anal intercourse and high number of sexual partners
Men who have sex with men
HIV-positive

Immunosuppression in transplant recipients
Cigarette smoking
Previous malignancy

41

Describe the presentation of anal cancer

Rectal bleeding (50%)
Perianal pain
Palpable lesion
Faecal incontinence +/- mucus discharge
Perianal pruritus

20% asymptomatic

42

How should anal cancer be investigated?

Rectal examination and biopsy
Staging: CT, MRI, endo-anal USS, PET
HIV serology
Metastases screening

43

What system is used to stage anal cancer?

TNM staging

44

Outline management of small well-differentiated carcinomas of the anal margin

Local excision

45

Outline management of anal cancers that are larger, poorly-differentiated, or outside of the anal margin

Combined modality chemotherapy (5-fluorouracil + mitomycin C) and radiotherapy
Salvage surgery

46

What are the surgical indications for anal cancer?

Tumours that fail to respond to radiotherapy
Large tumours causing GI obstruction
Small anal margin tumours without sphincter involvement

47

Outline the pharmacological management of acute anal fissures

Bulk forming laxatives
Non-opioid analgesia
Topical anaesthetic