GC179 Anal Pain Perianal Lesions And Sepsis
Anal pain with perianal lesions and sepsis encompasses conditions such as perianal abscesses, fistulae, fissures, and thrombosed hemorrhoids that may present with localized pain, swelling, and potential systemic infection if inadequately treated.
Anal Pain, Perianal Lesions and Sepsis
Big Idea: This lecture covers the systematic approach to common anorectal conditions — from history and examination through to specific disease management. The vast majority of anorectal pathology is benign, but the critical exam skill is knowing when to suspect something sinister (colorectal neoplasm, IBD, anal cancer) lurking behind "simple" symptoms like bleeding and pain.
Learning Objectives (from the deck): [1]
- Common presentations of anorectal diseases
- Evaluation and assessment of anorectal conditions
- Diagnosis and management of specific diseases
How this fits into exams and clinical practice:
- Anorectal conditions are bread-and-butter surgical topics. They appear as MCQ discriminators (e.g., Crohn's vs UC perianal disease), SAQ management plans, and OSCE stations (DRE technique, proctoscopy).
- The key principle: most anorectal conditions are benign, but colorectal neoplasm must always be excluded [1]. This is the slide the examiner will test.
- Perianal disease is also a major crossover topic with IBD (especially Crohn's disease), dermatology, STI, and immunodeficiency lectures.
Core Concepts and Mechanisms
The dentate line (pectinate line) is the single most important anatomical landmark in anorectal surgery. It is the junction between the embryological endoderm (hindgut) above and ectoderm (proctodeum) below. Nearly every clinical distinction in this lecture hinges on it:
| Feature | Above Dentate Line | Below Dentate Line |
|---|---|---|
| Epithelium | Columnar (mucosa) | Squamous (skin) |
| Nerve supply | Autonomic (visceral) → painless | Somatic (pudendal/inferior rectal) → painful |
| Venous drainage | Superior rectal vein → portal system | Inferior rectal vein → systemic (IVC) |
| Lymphatic drainage | Internal iliac nodes | Inguinal nodes |
| Relevance | Internal haemorrhoids (painless unless complicated) | External haemorrhoids (painful if thrombosed), anal fissure |
Internal haemorrhoids are proximal to the dentate line, covered by columnar epithelium (mucosa), and have NO nerve endings — hence painless unless complicated. External haemorrhoids are distal to the dentate line, covered by squamous epithelium (skin), with nerve endings — hence painful. [1]
Anal cushions are normal vascular structures at 3, 7, and 11 o'clock positions (lithotomy) that aid in continence by acting as a plug and protect the sphincter from defecation trauma [1][2]. Haemorrhoids are pathological engorgement and prolapse of these cushions.
Anal canal musculature:
- Internal anal sphincter (IAS): smooth muscle, involuntary, continuous with the circular muscle of the rectum. Maintains resting anal tone (~70-80% of resting pressure). This is the target in lateral internal sphincterotomy for fissure.
- External anal sphincter (EAS): skeletal muscle, voluntary, supplied by pudendal nerve. Maintains squeeze pressure.
- Intersphincteric space: the potential space between IAS and EAS — this is where cryptoglandular abscesses originate.
The anal glands sit in the intersphincteric space and drain into the anal crypts at the dentate line. Infection of these glands is the basis for most anorectal abscesses and fistulae. The pus can track in multiple directions depending on which tissue planes it dissects through — hence the classification of abscesses and fistulae.
Clinical Approach — History and Examination
Common anorectal symptoms: Bleeding (usually fresh blood), Anal pain, Discharge (blood or purulent), Prolapse, Perianal mass, Pruritus ani, Incontinence [1]
History must include: [1]
- Present illness — anorectal symptoms: pain, bleeding, mass, prolapse
- Past health — medical diseases, previous surgery
- Family history — colorectal cancer, IBD, polyposis syndromes
- Sexual history — critically important for STIs (syphilis, HPV, HIV, gonorrhoea), anal cancer risk
Pain characterization: [1]
- Duration, characteristics (sharp/dull/burning), constant vs intermittent
- Association with bowel movements, bleeding, or other factors [1]
- Pain on defecation → think fissure
- Constant throbbing pain → think abscess
- Pain with prolapse → think thrombosed or incarcerated haemorrhoid
Bleeding characterization: [1]
- Onset and duration
- Bright red vs altered blood [1]
- On paper / in bowl / on stool / in stool [1] — this is a classic discriminator:
- On paper after wiping → haemorrhoids, fissure
- In the bowl (dripping) → haemorrhoids
- On stool (coating) → low rectal/anal lesion
- Mixed in stool → higher lesion (proximal rectum/colon)
- Association with bowel movements and pain [1]
- Black, tarry stools → upper GI source, requires different workup entirely
Examination sequence: [1]
- General examination — pallor (chronic blood loss), cachexia (malignancy), lymphadenopathy
- Abdominal examination — masses, organomegaly, signs of IBD
- Perianal examination — patient in left lateral position (standard UK/HK) or prone jackknife position [1]
- Digital rectal examination (DRE)
- Proctoscopy
Inspection: [1]
- Look for skin tags, external haemorrhoids, fissure, fistula openings, condylomata, ulcers, prolapse, erythema/swelling of abscess
Palpation (DRE): [1]
- Pain, masses, induration, sphincter tone (at rest and on squeeze), prostate/rectovaginal septum
- In acute fissure: DRE and proctoscopy are painful and NOT indicated [1] — diagnosis is made by inspection (spreading buttocks)
Anoscopy/Proctoscopy: [1]
- Visualizes the anal canal and lower rectum
- Essential for grading internal haemorrhoids
Investigations serve to: (1) help diagnosis and assess severity, (2) define anatomy of the pathological process (abscess/fistula), (3) exclude diseases in the proximal bowel and associated bowel problems (e.g. IBD) [1]
| Investigation | Purpose | Details |
|---|---|---|
| Rigid sigmoidoscopy | Exclude rectal pathology | Views up to ~25 cm; can biopsy |
| Flexible endoscopy | Exclude proximal bowel lesion | Colonoscopy for cancer/IBD screening |
| Transrectal ultrasound (TRUS) | Staging of rectal cancer; assess sphincter muscles in faecal incontinence; assess complex fistula [1] | |
| MRI | Accurate for primary fistula track and extensions; for complicated abscesses/fistulas [1] | Gold standard for complex fistula anatomy |
| Defaecography | Patient with constipation [1] | Assesses pelvic floor function |
| Fistulogram | Delineates fistula tract | Less used now with MRI availability |
| Anorectal manometry | Objective tests for anorectal function; to investigate constipation and incontinence [1] | |
| EMG / Pudendal nerve latency | Assess nerve function | For documentation and assessment after treatment [1] |
Specific Diseases — Slide-by-Slide High-Yield Content
Cushions of vascular tissue at the anal canal. Aid in continence (act as a plug). Protect sphincters/anus from the trauma of defecation. [1]
Epidemiology: [1]
- 4.4% of US population seen by physician for symptomatic haemorrhoids
- 49/100k US population undergo haemorrhoidectomy annually
Aetiology: [1]
- Constipation, straining, pregnancy, low fibre diet, family history [1]
- The mechanism: chronic straining → ↑ intra-abdominal pressure → engorgement of vascular cushions → degeneration of supporting fibroelastic tissue → prolapse [2]
Classification of Internal Haemorrhoids: [1]
| Grade | Description |
|---|---|
| 1st degree | Does not prolapse out of anal canal |
| 2nd degree | Prolapse out of anal canal and reduce spontaneously |
| 3rd degree | Requires manual reduction |
| 4th degree | Cannot be reduced (incarcerated) |
Symptoms: [1]
Bleeding, Prolapse (mass), Mucus discharge, Pruritus. Pain occurs ONLY when complications are present (thrombosis, prolapse). [1]
This is a high-yield exam discriminator: uncomplicated internal haemorrhoids are painless. If a patient presents with bleeding AND significant pain, think fissure, abscess, or thrombosed external haemorrhoid — not simple internal haemorrhoids.
Assessment: [1]
- DRE (to exclude other rectal lesions) [1]
- Proctoscopy: for diagnosis and assessment of severity [1]
- Rigid or flexible sigmoidoscopy to exclude proximal bowel lesion [1]
Critical Concept
You CANNOT diagnose haemorrhoids by DRE alone — they are soft vascular cushions that collapse on palpation. You need proctoscopy. DRE is done to exclude other lesions (rectal mass).
Treatment: [1]
| Severity | Treatment |
|---|---|
| All grades (conservative) | Diet modification: high fibre diet; Sitz bath (for prolapsed haemorrhoids); Ointments and suppositories (may help but some contain steroid) [1] |
| Grade 1-2 (office procedures) | Banding, Sclerotherapy, Infrared coagulation [1] |
| Grade 3-4 / mixed / failed conservative | Surgical haemorrhoidectomy [1] |
Surgical Haemorrhoidectomy: [1]
Excision of haemorrhoids. Indications: Severe haemorrhoids (3rd or 4th degree), Mixed internal and external haemorrhoids, Failure of other treatments, Patient preference, In conjunction with another procedure. [1]
Complications of haemorrhoidectomy: [1]
Bleeding, Urine retention, Pain, Faecal impaction, Infection, Anal tags, Anal stenosis, Incontinence [1]
Stapled Haemorrhoidopexy: [1]
Uses a stapling device to remove a ring of rectal mucosa and submucosa with creation of a mucosal anastomosis above the dentate line. Haemorrhoids are NOT excised. Haemorrhoidal tissues pulled back into the anal canal from the prolapsed position. Interruption of blood supply to the haemorrhoids. [1]
Outcomes of stapled haemorrhoidopexy vs conventional: [1]
| Feature | Stapled Haemorrhoidopexy | Conventional Haemorrhoidectomy |
|---|---|---|
| Pain | Less pain, less analgesic | More pain |
| Recovery | Quicker recovery, shorter hospital stay | Longer |
| Patient satisfaction | Higher | Lower |
| Postop bleeding/wound complications | Less | More |
| Serious complications | Can be serious: rectal perforation, severe pelvic sepsis, rectovaginal fistula | Rare |
| Recurrence | More recurrence | Gold standard |
Transanal Haemorrhoidal Artery Devascularization (THD): [1]
Reduces blood flow to haemorrhoids. Involves inserting a small ultrasound probe into the anus to locate the vessels supplying the haemorrhoids. Each blood vessel is stitched closed to block the blood supply. [1]
A split in the anoderm at the dentate line. 90% at posterior midline. Anterior midline fissure occurs in 10% of women. [1]
Why posterior midline? The posterior commissure has the poorest blood supply (the terminal branches of the inferior rectal artery are "watershed" here). The external sphincter splits posteriorly, offering less support. This creates a vulnerable zone for ischaemia and tearing.
Aetiology: [1]
Hard stool, tight internal anal sphincter, ischaemia of the overlying anoderm at the posterior midline [1]
The vicious cycle: hard stool → tears anoderm → pain → sphincter spasm → ↓ blood flow → impaired healing → chronic fissure → more spasm. This is why treatment targets reducing sphincter pressure.
Chronic fissure features (triad): [1]
Sentinel pile (external skin tag), Hypertrophic papilla (internal), Internal sphincter muscle visible at base of fissure [1]
Atypical fissures (red flag): [1]
Atypical position and multiple in number → consider: inflammatory bowel disease, tuberculosis, syphilis, HIV infection, CMV [1]
This is an important exam discriminator: a lateral fissure, or multiple fissures, should raise suspicion for secondary causes (especially Crohn's disease or STI).
Clinical features: [1]
Pain on defecation, fresh rectal bleeding. Diagnosis is by spreading the buttock to reveal the fissure. Rectal examination and proctoscopy are painful and NOT indicated. [1]
Treatment: [1]
Non-operative: [1]
Bulk agents, stool softeners and topical anaesthetics. Newer topical agents to reduce internal sphincter pressure: Nitroglycerin (GTN), Calcium channel blocker (e.g. diltiazem), Botulinum toxin [1]
Why these work: GTN donates nitric oxide → relaxes smooth muscle of IAS → ↓ resting anal pressure → ↑ blood flow to posterior midline → promotes healing. Calcium channel blockers work similarly. Botulinum toxin paralyzes the sphincter temporarily.
Operative: [1]
Lateral internal sphincterotomy is the commonest surgery for anal fissure. Healing rate: 95%. Incontinence: 0-15%, most are minor with flatus incontinence. [1]
The surgery divides the lower portion of the IAS laterally (NOT posteriorly, because the posterior midline already has a "keyhole" defect from the fissure — cutting there would worsen it). This permanently reduces resting pressure.
Exam Trap — Fissure vs Haemorrhoid Pain
Haemorrhoids are painless unless complicated (thrombosis/prolapse). Fissure causes sharp pain ON defecation with a tearing quality. If the question says "pain on defecation with fresh bleeding," think fissure first, not haemorrhoids.
Aetiology: [1]
Cryptoglandular infection (most common). Specific infections: IBD, tuberculosis, actinomycosis. Foreign body. Surgery. Malignancies. [1]
Clinical features: [1]
Pain, Swelling, Drainage, Constipation, Urinary difficulties [1]
Classification by anatomical location: [1]
| Type | Frequency | Location |
|---|---|---|
| Ischiorectal | 60% | Between levator ani and skin, lateral to sphincters |
| Perianal | 20% | Superficial, around anal verge |
| Intersphincteric | 18% | Between IAS and EAS |
| Supralevator | 2% | Above levator ani — the most dangerous, can be missed |
High Yield
The most common anorectal abscess is ischiorectal (60%), NOT perianal. This is a common exam trap. Perianal abscesses are most visible externally but ischiorectal ones are more common overall per this lecture slide [1].
Treatment: [1]
Incision and drainage of abscess. Little role for antibiotics EXCEPT in patients with severe cellulitis, valvular heart disease, prosthetic heart valves, and immunosuppression. ?Primary fistulotomy. [1]
Why antibiotics are not routinely needed: The abscess is a walled-off collection of pus. Antibiotics cannot penetrate an abscess cavity well. The definitive treatment is surgical drainage to evacuate the pus. Antibiotics are reserved for those at high risk of bacteraemia/sepsis or endocarditis.
Key principle: ~30-50% of anorectal abscesses will develop into a fistula-in-ano after drainage. This is because the cryptoglandular infection creates a track. Whether to perform primary fistulotomy at the time of abscess drainage is debated (risk of incontinence vs recurrence).
Abnormal tract communicating the rectum or anal canal [to the perianal skin]. Cryptoglandular infection [is the underlying cause]. [1]
Parks Classification: [1]
| Type | Description |
|---|---|
| Intersphincteric | Track through IAS, in intersphincteric space, exits perianally. Most common (~45%). |
| Transphincteric | Track through both IAS and EAS into ischiorectal fossa. (~30%) |
| Suprasphincteric | Track up over top of EAS and through levator ani. Rare. |
| Extrasphincteric | Track from rectum through levator ani to perianal skin, bypassing sphincters entirely. Rarest. Often secondary (e.g., Crohn's, trauma, malignancy). |
Clinical features: [1]
Drainage, pain, bleeding, swelling, decrease in pain with drainage, external opening visible, PR: induration with cord-like structure [1]
Goodsall's Rule (not explicitly on slides but commonly examined):
- External opening anterior to the transverse anal line → track runs directly (radially) to the nearest crypt
- External opening posterior to the transverse anal line → track curves to the posterior midline internal opening
Diagnosis: [1]
Clinical examination. MRI in cases of: complicated high fistula, recurrent fistula, when anatomy is not obvious [1]
Treatment: [1]
| Fistula Type | Treatment |
|---|---|
| Simple low fistula | Fistulotomy / fistulectomy. Risk of incontinence should be informed. [1] |
| Complicated high fistula or transphincteric fistula with significant muscle involvement | Seton (staged procedure), Endorectal advancement flap, Anal fistula plug, LIFT (Ligation of Intersphincteric Fistula Tract) [1] |
Other treatment modalities: [1]
VAAFT (Video-Assisted Anal Fistula Treatment), FiLaC (Fistula tract Laser Closure), Permacol paste injection, Stem cell treatment [1]
Why seton? A seton is a thread/rubber band passed through the fistula tract. It allows ongoing drainage (prevents recurrent abscess), induces fibrosis that gradually cuts through the sphincter while healing occurs behind it (cutting seton), or simply holds the tract open until definitive repair (draining seton). In complex fistulas, cutting straight through would divide too much sphincter muscle → incontinence.
IBD connection: Perianal fistulae are extremely common in Crohn's disease (up to 40%) [3][4]. In Crohn's, management is different: immunomodulators (azathioprine) and biologics (infliximab/adalimumab) are used alongside surgical options. Simple fistula → fistulotomy; complex fistula → seton + biologics [4][6].
Occurs in 1-5% of the population. Common in 5th and 6th decades. Itchiness in the perianal region. Scratching leads to excoriation and secondary infection. [1]
Aetiology: [1]
Personal hygiene, diet, systemic diseases, dermatological conditions, neoplasm, infection, psychogenic, drugs, diarrhoea, idiopathic [1]
Approach: [1]
Identify aetiology and treat appropriately. For idiopathic: reassurance, keep perianal skin dry, avoid soap and local applications, avoid prolonged topical steroids, dietary change [1]
Common dietary triggers: coffee, alcohol, spicy foods, citrus, tomatoes, chocolate. The mechanism involves irritation of perianal skin by these substances in stool.
Full thickness protrusion of the rectum through the anal sphincters. Internal prolapse: rectum intussuscepts but does not pass beyond the anus. Occurs at any age but more commonly at extremes of life. [1]
Anatomical abnormalities: [1]
Rectal intussusception, deep cul-de-sac, loss of rectal fixation, redundant sigmoid, levator ani diastasis, patulous anal sphincter, pudendal neuropathy [1]
Aetiology: [1]
Neurological disorders, parity, 25-50% associated with constipation. Childhood: cystic fibrosis, whooping cough, developmental abnormalities and malnutrition. [1]
Symptoms: [1]
Incontinence, constipation, protrusion, bleeding, discharge, sensation of incomplete emptying, rectal pressure/tenesmus [1]
Distinguishing prolapse from prolapsed haemorrhoids:
- Full thickness rectal prolapse: concentric mucosal folds (rings)
- Prolapsed haemorrhoids: radial grooves between individual cushions
Treatment: [1]
| Approach | Options |
|---|---|
| Abdominal repair | Rectal fixation (suture/mesh), Sigmoid resection, Proctectomy, Combination of rectal fixation and sigmoid resection [1] |
| Perineal repair | Full thickness resection (perineal rectosigmoidectomy / Altemeier), Mucosal resection with muscular reefing (Delorme), Anal encirclement (Thiersch) [1] |
Abdominal approach generally preferred in fit patients (lower recurrence). Perineal approach preferred in frail/elderly patients who cannot tolerate general anaesthesia/laparotomy.
Laparoscopic ventral mesh rectopexy: [1]
Systematic review in 2010 of 12 non-randomised studies, 728 patients. Recurrence of 3.4%. Improvement in incontinence of 45%. Improvement in constipation of 24%. [1]
Epidermoid Carcinoma of Anal Canal: [1]
Risk factors: anal intercourse, sexually transmitted diseases, infection with human papillomavirus (HPV). Presented with bleeding, pain and anal mass. [1]
Treatment: chemoradiation. APR for residual or recurrent disease. Prognosis: 5-year survival 80-90%. [1]
This is the Nigro protocol — concurrent 5-FU + mitomycin C + radiation. Surgery (APR) is reserved for failures. This is a paradigm shift from the old approach of primary surgery.
Anal Melanoma: [1]
Accounts for 1% of all melanoma. Bleeding, pain and mass. Locally invasive and high metastatic potential. Patients treated with curative intent have survival of 6-20%. APR vs. wide local excision. Current treatment with immunotherapy with favorable outcome. [1]
Anal Margin Cancers: [1]
Squamous cell carcinoma, Basal cell carcinoma, Kaposi's sarcoma [1]
Common anorectal conditions are mostly benign. Colorectal neoplasm needs to be excluded. Diagnosis can usually be made by careful history and examination. Treatment is mainly for symptomatic control. [1]
Integration with Related Material
- Perianal disease occurs in up to 40% of Crohn's disease patients [3][4]
- Perianal features include: abscess, fistula, anal fissures (often atypical — lateral, multiple), skin tags [4]
- In Montreal classification for CD, "P" modifier indicates perianal disease [4]
- Management of Crohn's perianal disease: EUA + abscess drainage, ciprofloxacin/metronidazole, simple fistula → fistulotomy, complex fistula → seton + azathioprine/biologics (infliximab/adalimumab) [6]
| Condition | Pain Character | Bleeding | Mass | Key Feature |
|---|---|---|---|---|
| Anal fissure | Sharp, on defecation | Bright red, small amount | Sentinel pile (chronic) | Posterior midline, visible on inspection |
| Thrombosed external haemorrhoid | Acute, constant, severe | Minimal unless ulcerated | Blue/purple tender lump | Sudden onset, cannot be reduced |
| Anorectal abscess | Throbbing, constant, worsening | Rare unless draining | Tender, fluctuant swelling | Fever, cellulitis |
| Fistula-in-ano | Intermittent, ↓ with drainage | Possible | Induration/cord | External opening with discharge |
| Proctalgia fugax | Severe spasm, brief (minutes), often nocturnal | None | None | Diagnosis of exclusion |
| Anal cancer | Dull, progressive | Yes | Hard, fixed mass | Risk factors: HPV, MSM |
| Perianal Crohn's | Variable | Variable | Tags, fistulae | Associated bowel symptoms, atypical fissures |
Common Exam Traps and Discriminators
- Haemorrhoids are painless unless thrombosed or prolapsed. If the stem gives pain + bleeding → think fissure first.
- Fissure location matters: posterior midline is typical; lateral or multiple = secondary cause (IBD, STI, TB).
- DRE not indicated in acute fissure — diagnosis is clinical by inspection.
- Anorectal abscess treatment = I&D, NOT antibiotics (unless cellulitis, immunosuppression, or prosthetic valves).
- Ischiorectal abscess is the most common type (60%) per the lecture slides, not perianal.
- Stapled haemorrhoidopexy has less pain but higher recurrence and risk of serious complications (rectal perforation, pelvic sepsis).
- Anal canal SCC (epidermoid) = chemoradiation first, NOT surgery. Surgery (APR) only for residual/recurrent disease.
- Recurrent perianal abscess in a young patient → think Crohn's disease.
- Perianal disease + RLQ tenderness = Crohn's until proven otherwise.
- Lateral internal sphincterotomy is the definitive surgery for chronic anal fissure, NOT posterior midline sphincterotomy.
Past Paper Questions
Stem: "A 20-year-old man presented with repeated perianal abscess in the past few years. He also complained of increasing abdominal pain and weight loss recently. Physical examination found mild tenderness over right lower quadrant and perianal fistula. What is the MOST LIKELY diagnosis?"
Options: A. Crohn disease, B. Diverticulitis, C. Indeterminate colitis, D. Ulcerative colitis
Correct Answer: A. Crohn disease
Rationale: Recurrent perianal abscess + perianal fistula + RLQ tenderness + weight loss in a young patient is classic Crohn's disease. Up to 40% of CD patients have perianal disease [3]. UC rarely causes perianal disease [3]. Diverticulitis is a disease of older patients and does not cause perianal fistulae. Indeterminate colitis is a histological diagnosis when features overlap between UC and CD — it would not present with this classic pattern.
Stem: "An 18-year-old girl presented with recurrent abdominal pain and diarrhoea for 1 year. She has lost 5 kg over the past few months. Physical examination showed the presence of mild right lower quadrant abdominal tenderness and perianal skin tags. Colonoscopy showed multiple ulcerations in terminal ileum and caecum. What is the BEST small bowel examination for this patient?"
Options: A. CT enterography, B. Faecal calprotectin, C. MR enterography, D. Small bowel capsule endoscopy
Correct Answer: C. MR enterography
Rationale: This is a young patient with likely Crohn's disease (terminal ileum ulceration, perianal skin tags, weight loss). MR enterography is preferred over CT enterography in young patients to avoid radiation exposure, especially given the need for repeated imaging over a lifetime of IBD. Faecal calprotectin is a screening test, not an imaging modality. Small bowel capsule endoscopy is contraindicated if stricturing disease is suspected (risk of capsule retention), and the question asks for the best small bowel examination — MRE provides both luminal and extraluminal assessment.
High Yield Summary
Haemorrhoids: Grade 1-2 → conservative/office procedures (banding); Grade 3-4 → haemorrhoidectomy. Pain only with complications. Fissure-in-ano: 90% posterior midline; lateral/multiple = IBD/STI. Treat with GTN/diltiazem → lateral internal sphincterotomy if failed. DRE not indicated. Anorectal abscess: Commonest = ischiorectal (60%). Treatment = I&D, antibiotics only if cellulitis/immunosuppression/valve disease. ~30-50% develop fistula. Fistula-in-ano: Cryptoglandular origin; Parks classification. Simple → fistulotomy; complex → seton/LIFT/flap. MRI for complex/recurrent cases. Rectal prolapse: Abdominal repair (lower recurrence) vs perineal repair (for frail patients). Anal cancer: Epidermoid → chemoradiation (Nigro protocol); melanoma → poor prognosis, immunotherapy emerging. Always exclude colorectal neoplasm and IBD in patients with anorectal symptoms.
Active Recall - Lecture Notes
[1] Lecture slides: GC 179. Anal pain perianal lesions and sepsis.pdf (all pages) [2] Senior notes: Maksim Surgery Notes.pdf (p.109, Diseases of anal canal & anus) [3] Lecture slides: Inflammatory bowel disease.pdf (p.6, Disease pattern table) [4] Senior notes: Maksim Medicine Notes.pdf (p.130, Extra-intestinal manifestation of IBD / Montreal classification) [5] Senior notes: MBBS Final MB (Pediatrics) (Felix PY Lai).pdf (p.574, Neutropenic fever examination) [6] Senior notes: MBBS Final MB (Medicine) (Felix PY Lai).pdf (p.863, Perianal disease management in CD) [7] Senior notes: Jerry's immunodeficiencies.pdf (p.3, IL-10 receptor deficiency) [8] Senior notes: Ryan Ho Urogenital.pdf (p.245, Primary syphilis) [9] Past papers: 2020 Fourth Summative Assessment MCQ paper.pdf (Q32) [10] Past papers: 2021 Fourth Summative Assessment MCQ.pdf (Q44)
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