Flashcards in ANORECTAL CONDITIONS Deck (28)
What are haemorrhoids?
Capillary bed cushion which result from enlarged venous plexuses at the lower end of the anal mucosa. They are caused by raised intra-abdominal pressure which inhibits venous return and hence causes venous engorgement.
What are the risk factors for developing haemorrhoids?
Low fibre diet
Excessive straining to pass urine or stool
Pregancy - both because of pressure and oestrogen-related venous dilation
How do people with haemorrhoids typically present?
Rectal bleeding, which may coat the stool, drip into the toilet or just be on the toilet paper.
Perianal irritation and itching.
Symptoms are intermittent and precipitated by constipation.
How might you investigate someone who presents with a history consistent with haemorrhoids?
Where in the anal canal do haemorrhoids typically develop?
At the 3, 7 and 11 positions with the patient supine in the a trendelenberg position (face upwards with head below pelvis)
How are haemorrhoids classified?
First degree - no prolapse
Second degree - prolapse on defecation but spontaneous reduce
Third degree - Require digital reduction or persistently prolapsed
What are the complications of haemorrhoids?
Thrombosis of the haemorrhoids is painful and irreducible. It is however a self limiting condition that eventually results in atrophy and fibrosis. Leaves behind visible anal tags.
How are haemorrhoids treated?
Mild cases can be improved by reversing constipation through diet advice or defecation therapy.
Injection of sclerosant or elastic band ligation may be needed in troublesome cases
Surgical resection is reserved for irreducible prolapsed and problematic cases.
What is an anal fissure?
A tear or ulcer that develops in the lining of the anal canal. The pain associated with the tear causes anal spasm which in turn aggravates the constipation that caused the condition originally.
Where in the anal canal are most anal fissures found?
90% are in the posterior margin
What are the clinical features of an anal fissure?
Rectal pain during defecation
Rectal examination is often not possible due to extreme pain.
How are anal fissures treated?
Acute fissures - local anaesthetic and prevention of constipation with bulking agent or osmotic laxative
Chronic fissuring - surgical. Lateral internal sphincterotomy.
Glyceryl trinitrate ointment may help.
What is pruritus ani?
Redness around the anus. Usually secondary to poor hygiene and incontinence. Associated conditions such as haemorrhoids, threadworm infestation or fungal infection should be excluded.
How is pruritus ani treated?
Good personal hygiene
Keep area dry
Avoid topical steroids
What is rectal prolapse?
Where the walls of the rectum begin to prolapse out through the anal canal. Partial prolapse is when the prolapse involves only the mucosa and the prolapse does not occur beyond the external sphincter. Complete prolapse involves both the mucosa and the muscles layers and they prolapse outside the anal sphincter.
What causes rectal prolapse?
Excessive straining when opening bowels.
What are the clinical features of rectal prolapse?
Tenesmus - feeling of incomplete defecation
Rectal bleeding - mucosal ulceration
Incontinence of faeces can be a factor
Prolapse can be seen when patient strains
How would investigate someone with suspected rectal prolapse?
Endoscopic ultrasound - determines whether there is muscle damage
How is rectal prolapse treated?
Mild - High fibre diet, Avoiding straining
Severe - posterior fixation of the rectum to the sacral wall. Sphincter repair may also be necessary with incontinence.
What is an anorectal abscess?
An abscess adjacent to the anus. It arises from an infection at one of the anal glands which leads to inflammation and abscess formation which spreads along the anal duct through the external anal sphincter in the wall of the anal canal.
Which chronic patients are more likely to develop an anorectal abscess?
What are the clinical features of an anorectal abscess?
Fluctuant mass sitting just beneath inflamed skin - perianal or ischiorectal abscess
Tender mass on rectal examination - intersphincteric or pararectal abscess
What investigations would you order for someone with a suspected anorectal abscess?
Flexible sigmoidoscopy to look for signs of Crohns
MRI to identify location if surgery required.
How do you manage someone with an anorectal abscess?
Surgical drainage is required in all cases
Antibiotics to cover skin organisms such as Staph, and gut bacteria including anaerobes.
What is an anal fistula (or fistula-in-ano)?
A chronic abnormal communication between the epithelialised surface of the anal canal and the perianal skin. It is a complication of anorectal abscesses. Associated with Crohn's disease.
What are the clinical features of an anal fistula?
Intermittent discharge over the peri-anal area from the fistula.
Fistula itself seen as small area of granulation tissue around anal margin.
How is an anal fistula examined?
Often under anaesthesia using probe to establish the site of proximal opening. Can also use a dye which is inserted into the distal opening (fistulogram)