Q: Make an exam oriented notes crisp notes with bullets points and important points from the given source A: Here are crisp, exam-oriented notes from all 8 pages covering Ulcerative Colitis, Haemorrhoids, Fissure-in-Ano, Fistula-in-Ano, and Anorectal Abscesses: --- ULCERATIVE COLITIS - Exam Notes Aetiology 4 theories - Infective - no definitive pathogen identified; Chlamydia, CMV, Clostridial toxin/RNA virus suggested but unproven - Nutritional - attempts to find nutritional cause proved fruitless - Psychosomatic - colectomy improves pre-existing morbid psychology; characteristic personality noted - Immunological - lymphocytes rendered cytotoxic to colonic epithelium; IgG antibodies to cow's milk; autoimmune hypothesis most accepted; cross-reaction between colonic epithelium and E. coli Pathology - Confined to mucosal and submucosal layers only - Rectum most commonly involved 90-95% - earliest site - Disease spreads proximally continuous, no skip lesions - key difference from Crohn's - In 10% cases, entire colon involved - Terminal ileum involved in 10% cases back-wash ileitis - Disease is always in continuity - NO skip lesions exam favourite Macroscopic Features - Superficial fissures, small regular pseudopolyps - Irregular, shallow, linear anastomosing ulcers with islands of swollen mucosa = pseudopolyps characteristic - Serosa normal for a long time - Mesentery contracted, oedematous, thickened - Large lymph nodes absent unlike Crohn's - Fistulas except perianal are rare in UC common in Crohn's Microscopic Features - Earliest lesion: crypt abscesses of Lieberkuhn neutrophils accumulate in crypt lumen - Crypt abscesses rupture → tiny ulcers or rupture into submucosa - Chronic: lymphocytes, plasma cells, macrophages infiltrate mucosa + submucosa - Pseudopolyp = inflamed, oedematous mucosa with granulation tissue proliferation - In fulminating UC + toxic megacolon: lesions may penetrate full thickness Clinical Forms 3 types Type Key Features ------------------- Chronic Continuous Gradual onset; diarrhoea worsens; lower abdominal cramp; tenesmus; weight loss/malnutrition Chronic Relapsing-Remitting Commonest form; exacerbations linked to stress, menstruation, pregnancy Acute Fulminant Very acute; 30-40 stools/day; fever up to 39-40°C; dehydration, hypocalcaemia, anaemia, hypoproteinaemia; 20% mortality; risk of perforation, haemorrhage, toxic megacolon Special Investigations 1. Barium Enema with caution in acute exacerbation: - Early: loss of haustration paralysis of muscularis mucosa - Progressive: irregularities, pseudopolyps - Advanced: rigid contracted tube pipe-stem colon - Straight X-ray: toxic megacolon = remarkable dilatation of colon with air - Free air in peritoneal cavity = perforation - Yearly barium + colonoscopy advised after 10 years malignancy risk 2. Sigmoidoscopy/Colonoscopy: - Rectum involved in 90-95% - Mucosa erythematous, granular, friable - Cobblestone + deep linear ulceration = Crohn's unusual in UC - 50% lesions proximal to splenic flexure 3. CT - helpful in acute diverticulitis mentioned in context Complications LOCAL 1. Haemorrhage 2. Perforation free or with abscess/fistula 3. Stricture + partial obstruction 4. Perianal/perirectal abscesses + fistulas 5. Toxic Megacolon most serious local complication 6. Carcinoma of colon important long-term complication Toxic Megacolon - High Yield - Manifestation of fulminating colitis - Cause: necrotising inflammation of smooth muscle; damage to myenteric plexus - Contributing factors: hypocalcaemia, hypoproteinaemia, anticholinergic drugs - Diagnosis: patient with acute colitis whose stools suddenly decrease + bloody rectal discharge + toxic + progressive abdominal distension + absent bowel sounds - X-ray: marked gaseous distension of transverse colon - Treatment: antibiotics + intestinal decompression + electrolyte correction + blood/albumin transfusions + IV alimentation --- HAEMORRHOIDS PILES - Exam Notes Definition - Dilated veins within anal canal in subepithelial region radicles of superior, middle and inferior rectal veins Classification Type Location Covering Colour ---------------------------------- Internal Within anal canal, internal to anal orifice Mucous membrane Bright red/purple External Outside anal orifice Skin - - Intero-external = both coexist - Sentinel pile = associated with fissure-in-ano, NOT haemorrhoid exam trap External Haemorrhoid Special Conditions - Dilatation of veins at anal verge - sedentary life, straining - Perianal haematoma/thrombosed external haemorrhoid - very painful; treat by incision under LA Aetiology of Internal Haemorrhoids - Hereditary - family history - Anatomical - absence of valves in superior haemorrhoidal veins; radicles unsupported in loose submucous tissue - Exciting causes Parks - straining to expel constipated stool; mucosal suspensory ligament stretched - Physiological - corpus cavernosum rectum arteriovenous communication hyperplasia - Diet - low roughage Western diet - Secondary to: carcinoma rectum, pregnancy, chronic constipation, micturition difficulty, portal hypertension Degrees of Prolapse - 1st degree: does NOT come out - 2nd degree: comes out during defaecation, reduces spontaneously - 3rd degree: comes out, needs manual reduction; stays reduced - 4th degree: permanently prolapsed; heaviness in rectum Primary Haemorrhoids - 3 positions Lithotomy - 3, 7 and 11 O'clock positions left lateral, right anterior, right posterior Clinical Features 1. Bleeding - bright red, painless, splashes in pan; 1st symptom exam favourite 2. Prolapse - later symptom 3. Pain - NOT characteristic unless thrombosis OR associated fissure-in-ano 4. Mucous discharge - prolapsed haemorrhoids; causes pruritus ani 5. Anaemia - long-standing, profuse bleeding Examination - Digital examination cannot feel uncomplicated pile unless thrombosed - Proctoscopy: reveals internal pile best method - Always precede haemorrhoid treatment with sigmoidoscopy + barium enema exam point Complications 1. Bleeding - main symptom; anaemia in 4th degree 2. Thrombosis - acute, extremely painful; external internal 3. Strangulation - 2nd degree most often; 'acute attack of piles' 4. Gangrene - arterial supply constricted 5. Fibrosis - follows thrombosis/strangulation 6. Suppuration - infection of thrombosed haemorrhoid 7. Pylephlebitis portal pyaemia - theoretical Treatment Conservative - Bowel regulation high residue diet + mild laxatives - mandatory first step - Topical ointments, suppositories Injection Therapy Sclerotherapy - Method: 5% phenol in almond/arachis oil 140 ml with 40 ml menthol = 30 ml Albright solution - Injected into submucosa at pedicle - Used for 1st degree and small 2nd degree haemorrhoids - Cure rate: 95%; recurrence: 15% in 3 years - Contraindicated in: prolapsed piles, arterial piles, infection Rubber Band Ligation RBL - Ideal for 1st and 2nd degree internal, without tags/external component - Band placed ≥1 cm above dentate line - Haemorrhoid necroses in 24-48 hrs, sloughs in 7 days - Disadvantage: pain first 24-48 hrs; secondary haemorrhage Cryosurgery - Liquid nitrogen at -160°C for 3 minutes - Pain-free; but profuse watery discharge for 2-4 weeks - Healing complete in 4-6 weeks Maximal Anal Dilatation Lord's Procedure - 3 fingers of both hands inserted; breaks "pecten bands" - Ideal for fissure-in-ano; also used for early haemorrhoids - Risk: incontinence especially in elderly with pelvic floor problems Haemorrhoidectomy - For large 3rd degree with associated tags + external plexus haemorrhoidectomy - Ligature and Excision Method most widely used today - Lithotomy position; V-cut on skin adjacent to pile; haemorrhoids fixed by mucosal suspensory ligament; transfixed with stout ligature silk or catgut - At conclusion: proctoscopy to check haemostasis - Main concern: postoperative pain + economic disadvantage --- FISSURE-IN-ANO - Exam Notes Definition + Key Facts - Tear of skin of lower half of anal canal - Most common in the posterior midline 90% - due to posterior angulation of anal canal - Anterior: only 10% in males; females slightly more common anteriorly 60:40 ratio - Anterior fissures in females explained by foetal head trauma on anterior anal wall during delivery Aetiology Primary Causes - Predominantly posterior midline due to: - a Posterior angulation of anal canal - b Relative fixation of anal canal posteriorly - c Divergence of external sphincter fibres posteriorly - d Elliptical shape of anal canal - Constipation - most common aetiological factor 1 - Spasm of internal sphincter - Hard stool passing through anal stricture Secondary Causes must remember - i Ulcerative colitis - ii Crohn's disease - iii Syphilis - iv Tuberculosis - Operation biopsy must be taken from chronic fissure to exclude these Pathology - Starts at dentate line sensitive skin = pain is main symptom - Acute fissure = tear of skin of lower half of anal canal; no inflammatory induration; sphincter spasm always present - Chronic fissure = deep canoe-shaped ulcer with thick oedematous margins - Upper end: hypertrophied anal papilla - Lower end: skin tag = sentinel pile - Base: scar tissue + internal sphincter muscle - Sphincter spasm always present Clinical Features - More common in women; age 30-50 years - Two main symptoms: Pain + Bleeding - Pain: sharp, biting, burning; starts with/after defaecation; lasts 1 hour or more; intolerable; main symptom - Bleeding: bright red streaks on toilet tissue NOT splashing - cf. haemorrhoids - Slight discharge may accompany chronic fissure - Pruritus ani may occur - Tightly closed puckered anus = pathognomonic - Digital examination: surface anaesthetic 5% xylocaine needed; chronic fissure palpable as crater at vertical fissure Examination - Tightly closed puckered anus - pathognomonic - Sentinel skin tag may/may not be present - Margins gently separated to inspect lower end - Acute fissure: not palpable - Chronic fissure: crater of vertical fissure felt Differential Diagnosis 1. Multiple fissures - consider AIDS HIV test mandatory 2. Carcinoma of anus - early stage may simulate; biopsy under GA 3. Tuberculous ulcer - undermined edge 4. Proctalgia Fugax - severe pain from rectum at irregular intervals; cramping; occurs at night; "levator syndrome"; no treatment but enthusiastic surgeons try dividing puborectalis should NOT be done - incontinence Treatment A. Acute Ulcers conservative - a Pain medication before anticipated bowel movement - b Stool softener - c Glyceryl trinitrate GTN ointment - NO donor; relaxes internal sphincter; heals majority; few side effects; diltiazem if GTN causes headache - d Soothing ointments doubtful efficacy - e Self-dilatation highly important 5% xylocaine + St. Marks dilator - f Long-acting local anaesthetic injection - little relief B. Chronic Ulcers surgical in majority 1. Anal Dilatation Lord's Procedure - Under GA; index and middle fingers of each hand inserted; maximal dilatation - Patient goes home same day; warn: may be faecal incontinence in 10% - Failure if excessive fibrosis + skin tag 2. Posterior Sphincterotomy + Fissurectomy - Lithotomy position + GA - Internal sphincter fibres divided + floor of fissure made smooth - If sentinel pile present: excised - Only superficial fibres of internal sphincter divided not entire thickness - Bowel moved on 3rd day; hip bath + anal passage daily - Convalescent period: 7-10 days; may be persistent mucous discharge 3. Lateral Anal Sphincterotomy most favoured for early cases - Internal sphincter divided away from fissure lateral position - Cannot take biopsy/excise ulcer in this approach - 10-12% patients: anal swelling/impaired stool control - Recurrent ulcers reported; convalescent period: 1 day; hospital stay: 4 days 4. Excision of Anal Ulcer + Skin Graft - unsuccessful; not recommended 5. Anal Advancement Flap - Fissure edges excised; full thickness skin flap slid over and sutured - Popular recently; no risk of damage to internal sphincter = no incontinence --- FISTULA-IN-ANO - Exam Notes Definition - Inflammatory track with external opening primary in perianal skin and internal opening secondary in anal canal/rectum - Lined by unhealthy granulation + fibrous tissue Cause - Usually originates from perianal abscess in intersphincteric space - As anal gland is deep to internal sphincter: duct opens in crypts of Morgagni at dentate line - Stasis + secondary infection → abscess → fistula formation - Other causes: b Ulcerative colitis, c Crohn's disease, d Tuberculosis, e Colloid carcinoma rectum Classification Low Level Fistula internal opening below anorectal ring - i Subcutaneous type - ii Submucous type - iii Intersphincteric type - iv Transphincteric type - v Suprashincteric type High Level Fistula internal opening above anorectal ring - i Extrasphincteric/Supralevator type - ii Transphincteric type low variety also - iii Pelvi-rectal fistula Key point: Low level fistula can be laid open without fear of permanent incontinence; high level = risk of incontinence Goodsall's Rule exam favourite - Draw transverse line through midpoint of anus - External opening POSTERIOR to line → track curves posteriorly → internal opening in posterior midline - External opening ANTERIOR to line → track runs straight → internal opening directly behind external opening - Exception: if external opening is anterior but 1.75 inches 3.7 cm from anus → track curves posteriorly → opens in posterior midline Clinical Features - Past history of perianal abscess formed, ruptured itself, left discharging sinus - Recurring abscesses if fails to heal - Tuberculosis = very common cause of multiple fistulae in India; solitary fistula with external opening within 3.7 cm of anus; much induration of skin + subcutaneous tissue; watery discharge = strongly suggests tuberculosis; induration around fistula = disturbed Investigations - Rectal examination - most important; internal opening felt by digital exam - Above anorectal ring = high fistula treatment different from low - Multiple internal openings possible with multiple external fistulae but may be single internal opening - Proctoscopy - visualise internal opening - Lipiodol injection - into external opening prior to X-ray; utility doubtful may cause recrudescence - Chest X-ray - exclude tuberculosis important Exclude before treating a Tuberculous proctitis, b UC, c Crohn's, d Bilharziasis, e Lymphogranuloma inguinale, f Colloid carcinoma Treatment Low Level Fistula - Fistula track laid open fistulotomy; lithotomy position; bidigital exam under GA - Probe inserted through external opening; tip cut through to internal opening - Track laid open; fibrous tissue scraped with Volkmann spoon OR whole track excised - Cavity packed with roller gauze; heals by granulation tissue High Level Fistula i Supralevator fistula - Secondary to Crohn's/UC/carcinoma/foreign body - Treat primary condition first; do NOT lay open causes incontinence ii Transphincteric fistula with perforating secondary track - Lower track opened as usual - Upper track: wide open with scraping using Volkmann spoon - Upper track heals by itself Alternatively: Seton technique - Heavy black silk or rubber band passed around deeper part of track - Tied loosely outside for 2 weeks → stimulates fibrosis of sphincter - After 6 weeks: remaining part including sphincter fibres excised - Fibrosis prevents retraction of cut sphincter fibres = Gabriel's two-stage operation - OR: stainless steel wire seton gradually tightened at dressings cutting seton so sphincter will not gape iii Horse-shoe fistula - Posterior midline internal sphincterotomy + laying open deep part of fistula track - Lateral tracks excised = Hanley's operation --- ANORECTAL ABSCESSES - Exam Notes Definition + Key Facts - Abscesses around lower rectum and anal canal - Important as they culminate in fistula-in-ano - Causative organism: usually E. coli; less commonly Staph aureus, Bacteroides, Streptococcus, B. Proteus - 90% start as infection of anal gland; 10% blood-borne e.g. extension of cutaneous boil Classification + Frequency Type Frequency ----------------- Perianal 60% most common Ischiorectal 30% Submucous - Pelvi-rectal - 1. Perianal Abscess - Cause: inflammation of anal gland → pus within internal sphincter → tracks down between internal sphincter + conjoined longitudinal muscle → superficial in perianal region; also from thrombosed external pile - Features: throbbing pain around anus; exaggerated during defaecation; fever, headache; angry lump at anal margin; tender cystic lump felt just below dentate line - Treatment: incision and drainage immediately + antibiotic cover - Cruciate incision on most prominent part - Sinus forceps into cavity to break loculi - Internal sphincter separated from mucosa; lower part of internal sphincter incised to prevent fistula formation - Skin edges incised to keep wound wide open - Sequelae if untreated: i rupture into anal canal, ii rupture to exterior causing fistula, iii pass laterally through external sphincter → ischiorectal abscess 2. Ischiorectal Abscess - Cause: i most common = extension of anal gland inflammation laterally through external sphincter; ii blood/lymph; iii penetrating injury; iv extension from pelvi-rectal abscess through hiatus of Schwalbe - Pathophysiology: ischiorectal fossa = fat, poorly vascularised; connected to opposite side posteriorly → can spread to opposite side if not treated early - Features: acute pain by side of anus; exaggerated during defaecation; brawny indurated swelling superficial to ischiorectal fossa - Treatment: under GA; cruciate incision on most prominent part; incisions extend more than edge of swelling; adequate skin excised; septa divided; hiatus of Schwalbe enlarged if from pelvi-rectal abscess above; whole cavity lightly packed with gauze; T-bandage 3. Submucous Abscess - Just deep to mucous membrane of anal canal above dentate line - Spread of infection from anal gland or after haemorrhoid injection - Drained by small incision by stretching anus or proctoscope 4. Pelvi-rectal Abscess - Above levator ani pelvic floor; below pelvic peritoneum - From: appendicitis, diverticulitis, salpingitis, parametritis - From below: extension of ischiorectal abscess overenthusiastic draining of ischiorectal abscess pushing probe/curette through pelvic floor attachment - Sequelae if untreated: burst into rectum OR pass through hiatus of Schwalbe → ischiorectal abscess - Treatment: drainage through fornix of vagina or through anterior wall of rectum --- High-Yield Exam Summary Points Fact Answer -------------- Most common form of UC Chronic relapsing-remitting UC pathology confined to Mucosa + submucosa only Skip lesion seen in Crohn's NOT UC Toxic megacolon mortality 20% Most common haemorrhoid symptom Bright red painless bleeding Pain not characteristic of haemorrhoid unless Thrombosis or fissure-in-ano Sentinel pile associated with Fissure-in-ano NOT haemorrhoid Most common fissure location Posterior midline 90% Most common cause of fissure Constipation Secondary fissure causes UC, Crohn's, Syphilis, TB Goodsall's rule exception Anterior external opening 1.75 inches from anus → opens posteriorly Most common anorectal abscess Perianal 60% Most common cause of multiple fistulae in India Tuberculosis High fistula = risk of Incontinence if laid open Gabriel's operation Two-stage seton for high fistula Hanley's operation Horse-shoe fistula treatment Haemorrhoid sclerosant 5% phenol in almond/arachis oil 3 positions of primary haemorrhoids 3, 7, 11 O'clock lithotomy
