Anorectal problems

Anorectal problems

·        Haemorrhoids:

o  Dilated veins beneath the submucosa. Bleeding from overlying mucosa

o  Don‟t cause pain unless prolapsed or thrombosed

o  Can cause Pruritis ani 

o  Treatment: injection with injected sclerosant (eg almond oil), banding (but infection and bleeding risk), infra-red coagulation

·        Rectal Prolapse:

o  Self-limiting in kids, in elderly due to weakened pelvic floor (childbirth or denervation)

o  Treatment is surgical, faecal incontinence improved in half

·        Rectal Cancer:

o  Majority can be felt on digital examination

o  Adenocarcinomas

o  Presentation: bleeding and tenesmus, rarely pain

o  Treatment: local excision or resection

·        Fissures:

o  Vertical tear in anoderm.  90% posteriorly

o  Acute or chronic

o  Vicious circle: tight internal anal sphincter ® tear ® reflect spasm ® constipation etc.

o  History: severe pain and bleeding on defaecation

o  Associated with high resting anal pressure 

o  Treatment: High fibre diet, lots of H2O, local analgesic cream, GTN paste (relaxes sphincter) (all conservative), limited internal sphincterotomy

·        Abscesses and fistulae:

o  Infection of tiny glands emptying at dentate line.

o  Infection can burrow into perianal fat or ischiorectal fat

o  Drainage may result in anal fistula

·        Pruritis Ani (itchy anus):

o  Usually worse at night

o  Causes by anal or dermatological conditions

o  Anal: haemorrhoids, keyhole deformity, pinworm infection, anal warts and cancers

o  Dermatological: Bowen‟s disease, Paget‟s disease of anus, eczema

o  Treatment: avoiding strong steroid creams, avoiding itching, and drying carefully

·        Anal warts: Condylomata acuminata.  Caused by HPV 8 and 11. Usually an STD

·        Anal Cancer: Uncommon. Spreads to inguinal glands. Can be adenocarcinoma, basaloid carcinoma (this and next two caused by HPV 16 and 18), squamous carcinoma, muco-epidermoid carcinoma, anal melanoma.

·        Perianal suppuration

·        Angiodysplasia (submucosal proliferation of vessels – associated with age and aortic stenosis)

·        Anal cancer (rare): related to HPV (as with cervical cancer) ® anal intraepithelial neoplasia. Risk factors as for cervical cancer (number of partners, age of first intercourse, etc). Above dentate line – endodermal origin ® adenocarcioma. Below dentate line – ectodermal origin ® squamous or basal cell carcinoma or melanoma