Theme: Proctology
A. Fissure in ano
B. Fistula in ano
C. Rectal prolapse
D. Juvenile polyps
E. Rectal adenoma
F. Intersphincteric abscess
G. Haemorroids
Please select the most likely underlying cause for the presentations described. Each
option may be used once, more than once or not at all.
1. A 21 year old female presents with a 24 hour history of increasingly severe ano-
rectal pain. On examination she is febrile and the skin surrounding the anus
looks normal. She did not tolerate an attempted digital rectal examination.
You answered Fissure in ano
The correct answer is Intersphincteric abscess
Theme from September 2012 Exam
The presence of fever and severe pain makes an abscess more likely than a
fissure. Although fissures may be painful they do not, in themselves, cause
fever. The usual management for this condition is examination of the ano-
rectum under general anaesthesia and drainage of the sepsis.
2. A 21 year old male presents with a 4 week history of frank, bright red, rectal
bleeding. This typically occurs post defecation into the toilet pan. He has a long
standing history of constipation and a previous fissure in ano. On examination
the skin surrounding the anus is normal and digital rectal examination is normal.
Haemorroids
Haemorroids are a common cause of bright red rectal bleeding. The bleeding is
typically painless. A history of constipation is usual and may have been
previously associated with a fissure (though this is less common). Haemorroids
are not always associated with external features and digital rectal examination is
usually unremarkable.
3. A 21 year old lady presents with a 6 month history of an offensive discharge
from the anus. She is otherwise well, but is increasingly annoyed at the need to
wear pads. On examination she has a small epithelial defect in the 5 o'clock
position, approximately 3cm from the anal verge.
, Fistula in ano
Fistulas usually occur following previous ano-rectal sepsis. The discharge may
be foul smelling and troublesome. Patients should be listed for examination
under anaesthesia. Fistulas which are low and have little or no sphincter
involvement are usually laid open.
Ano rectal disease
Location: 3, 7, 11 o'clock position
Haemorrhoids Internal or external
Treatment: Conservative, Rubber band ligation,
Haemorrhoidectomy
Fissure in ano Location: midline 6 (posterior midline 90%) & 12 o'clock position.
Distal to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal
papillae
Proctitis Causes: Crohn's, ulcerative colitis, Clostridium difficile
Ano rectal E.coli, staph aureus
abscess Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric
Anal fistula Usually due to previous ano-rectal abscess
Intersphincteric, transsphincteric, suprasphincteric, and
extrasphincteric. Goodsalls rule determines location
Rectal prolapse Associated with childbirth and rectal intussceception. May be
internal or external
Pruritus ani Systemic and local causes
Anal neoplasm Squamous cell carcinoma commonest unlike adenocarcinoma in
rectum
Solitary rectal Associated with chronic straining and constipation. Histology shows
ulcer mucosal thickening, lamina propria replaced with collagen and
smooth muscle (fibromuscular obliteration)
Rectal prolapse
Common especially in multiparous women.
May be internal or external.
Internal rectal prolapse can present insidiously.
External prolapse can ulcerate and in long term impair continence.
Diagnostic work up includes colonoscopy, defecating proctogram, ano rectal
manometry studies and if doubt exists and examination under anaesthesia.
Treatments for prolapse
, In the acute setting reduce it (covering it with sugar may reduce swelling.
Delormes procedure which excises mucosa and plicates the rectum (high
recurrence rates) may be used for external prolapse.
Altmeirs procedure which resects the colon via the perineal route has lower
recurrence rates but carries the risk of anastamotic leak.
Rectopexy is an abdominal procedure in which the rectum is elevated and
usually supported at the level of the sacral promontory. Post operative
constipation may be reduced by limiting the dissection to the anterior plane
(laparoscopic ventral mesh rectopexy).
Pruritus ani
Extremely common.
Check not secondary to altered bowel habits (e.g. Diarrhoea)
Associated with underlying diseases such as haemorrhoids.
Examine to look for causes such as worms.
Proctosigmoidoscopy to identify associated haemorrhoids and exclude cancer.
Treatment is largely supportive and patients should avoid using perfumed
products around the area.
Fissure in ano
Typically painful PR bleeding (bright red).
Nearly always in the posterior midline.
Usually solitary.
Treatment
Stool softeners.
Topical diltiazem (or GTN).
If topical treatments fail then botulinum toxin should be injected.
If botulinum toxin fails then males should probably undergo lateral internal
sphincterotomy and females and advancement flap.
Theme: Management of colonic polypoidal lesions
A. Reassure and discharge
B. Pan proctocolectomy
C. Hot biopsy
D. Snare polypectomy
E. Segmental colonic resection
F. Repeat endoscopy at 3 years
G. Repeat endoscopy at 1 year
H. Repeat endoscopy at 5 years
, Please select the most appropriate management for the scenario given. Each option
may be used once, more than once or not at all.
1. A 43 year old man is investigated for altered bowel habit. At colonoscopy he is
found to have a 2cm polyp on a long stalk in the proximal sigmoid colon. The
rest of the colonoscopy is normal. It bears no macroscopic features of
malignancy.
Snare polypectomy
Polyps on long stalks are best managed by snare excision. It is important to
retrieve the polyp for histology.
2. A 60 year old lady is investigated for abdominal pain. A polyp is identified at
the proximal descending colon, three small polyps are also noted in the sigmoid
colon. The largest lesion is removed by snare polypectomy and the pathology
report states that this polyp is a low grade dysplastic adenoma measuring 3cm in
diameter. The remaining lesions are ablated using diathermy.
You answered Segmental colonic resection
The correct answer is Repeat endoscopy at 1 year
She is at high risk of malignancy and should be closely followed up.
Fulguration of polyps without histology is unhelpful.
3. A 73 year old lady is investigated for anaemia. At colonoscopy she is found to
have a flat broad based lesion in the caecum. This is biopsied and the histology
report states that these have diagnostic features of an adenoma with high grade
dysplasia.
You answered Pan proctocolectomy
The correct answer is Segmental colonic resection
This is most likely a malignancy and should be resected.
Polypectomy of flat broad lesions in the
right colon is difficult and where concern
arises a right hemicolectomy is probably
the safest option.
A. Fissure in ano
B. Fistula in ano
C. Rectal prolapse
D. Juvenile polyps
E. Rectal adenoma
F. Intersphincteric abscess
G. Haemorroids
Please select the most likely underlying cause for the presentations described. Each
option may be used once, more than once or not at all.
1. A 21 year old female presents with a 24 hour history of increasingly severe ano-
rectal pain. On examination she is febrile and the skin surrounding the anus
looks normal. She did not tolerate an attempted digital rectal examination.
You answered Fissure in ano
The correct answer is Intersphincteric abscess
Theme from September 2012 Exam
The presence of fever and severe pain makes an abscess more likely than a
fissure. Although fissures may be painful they do not, in themselves, cause
fever. The usual management for this condition is examination of the ano-
rectum under general anaesthesia and drainage of the sepsis.
2. A 21 year old male presents with a 4 week history of frank, bright red, rectal
bleeding. This typically occurs post defecation into the toilet pan. He has a long
standing history of constipation and a previous fissure in ano. On examination
the skin surrounding the anus is normal and digital rectal examination is normal.
Haemorroids
Haemorroids are a common cause of bright red rectal bleeding. The bleeding is
typically painless. A history of constipation is usual and may have been
previously associated with a fissure (though this is less common). Haemorroids
are not always associated with external features and digital rectal examination is
usually unremarkable.
3. A 21 year old lady presents with a 6 month history of an offensive discharge
from the anus. She is otherwise well, but is increasingly annoyed at the need to
wear pads. On examination she has a small epithelial defect in the 5 o'clock
position, approximately 3cm from the anal verge.
, Fistula in ano
Fistulas usually occur following previous ano-rectal sepsis. The discharge may
be foul smelling and troublesome. Patients should be listed for examination
under anaesthesia. Fistulas which are low and have little or no sphincter
involvement are usually laid open.
Ano rectal disease
Location: 3, 7, 11 o'clock position
Haemorrhoids Internal or external
Treatment: Conservative, Rubber band ligation,
Haemorrhoidectomy
Fissure in ano Location: midline 6 (posterior midline 90%) & 12 o'clock position.
Distal to the dentate line
Chronic fissure > 6/52: triad: Ulcer, sentinel pile, enlarged anal
papillae
Proctitis Causes: Crohn's, ulcerative colitis, Clostridium difficile
Ano rectal E.coli, staph aureus
abscess Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric
Anal fistula Usually due to previous ano-rectal abscess
Intersphincteric, transsphincteric, suprasphincteric, and
extrasphincteric. Goodsalls rule determines location
Rectal prolapse Associated with childbirth and rectal intussceception. May be
internal or external
Pruritus ani Systemic and local causes
Anal neoplasm Squamous cell carcinoma commonest unlike adenocarcinoma in
rectum
Solitary rectal Associated with chronic straining and constipation. Histology shows
ulcer mucosal thickening, lamina propria replaced with collagen and
smooth muscle (fibromuscular obliteration)
Rectal prolapse
Common especially in multiparous women.
May be internal or external.
Internal rectal prolapse can present insidiously.
External prolapse can ulcerate and in long term impair continence.
Diagnostic work up includes colonoscopy, defecating proctogram, ano rectal
manometry studies and if doubt exists and examination under anaesthesia.
Treatments for prolapse
, In the acute setting reduce it (covering it with sugar may reduce swelling.
Delormes procedure which excises mucosa and plicates the rectum (high
recurrence rates) may be used for external prolapse.
Altmeirs procedure which resects the colon via the perineal route has lower
recurrence rates but carries the risk of anastamotic leak.
Rectopexy is an abdominal procedure in which the rectum is elevated and
usually supported at the level of the sacral promontory. Post operative
constipation may be reduced by limiting the dissection to the anterior plane
(laparoscopic ventral mesh rectopexy).
Pruritus ani
Extremely common.
Check not secondary to altered bowel habits (e.g. Diarrhoea)
Associated with underlying diseases such as haemorrhoids.
Examine to look for causes such as worms.
Proctosigmoidoscopy to identify associated haemorrhoids and exclude cancer.
Treatment is largely supportive and patients should avoid using perfumed
products around the area.
Fissure in ano
Typically painful PR bleeding (bright red).
Nearly always in the posterior midline.
Usually solitary.
Treatment
Stool softeners.
Topical diltiazem (or GTN).
If topical treatments fail then botulinum toxin should be injected.
If botulinum toxin fails then males should probably undergo lateral internal
sphincterotomy and females and advancement flap.
Theme: Management of colonic polypoidal lesions
A. Reassure and discharge
B. Pan proctocolectomy
C. Hot biopsy
D. Snare polypectomy
E. Segmental colonic resection
F. Repeat endoscopy at 3 years
G. Repeat endoscopy at 1 year
H. Repeat endoscopy at 5 years
, Please select the most appropriate management for the scenario given. Each option
may be used once, more than once or not at all.
1. A 43 year old man is investigated for altered bowel habit. At colonoscopy he is
found to have a 2cm polyp on a long stalk in the proximal sigmoid colon. The
rest of the colonoscopy is normal. It bears no macroscopic features of
malignancy.
Snare polypectomy
Polyps on long stalks are best managed by snare excision. It is important to
retrieve the polyp for histology.
2. A 60 year old lady is investigated for abdominal pain. A polyp is identified at
the proximal descending colon, three small polyps are also noted in the sigmoid
colon. The largest lesion is removed by snare polypectomy and the pathology
report states that this polyp is a low grade dysplastic adenoma measuring 3cm in
diameter. The remaining lesions are ablated using diathermy.
You answered Segmental colonic resection
The correct answer is Repeat endoscopy at 1 year
She is at high risk of malignancy and should be closely followed up.
Fulguration of polyps without histology is unhelpful.
3. A 73 year old lady is investigated for anaemia. At colonoscopy she is found to
have a flat broad based lesion in the caecum. This is biopsied and the histology
report states that these have diagnostic features of an adenoma with high grade
dysplasia.
You answered Pan proctocolectomy
The correct answer is Segmental colonic resection
This is most likely a malignancy and should be resected.
Polypectomy of flat broad lesions in the
right colon is difficult and where concern
arises a right hemicolectomy is probably
the safest option.
