CCE-CBD-186

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: What features suggest an anal fissure versus a perianal abscess?
• Prompt: How does this presentation differ from a thrombosed haemorrhoid?

Q2. What are your immediate management steps?

• Prompt: What pain management and stool softening strategies would you use?
• Prompt: When would you consider incision and drainage versus referral?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you reassure the patient about the nature of the condition?
• Prompt: What advice would you provide on wound care post-drainage?

Q4. What preventive measures can help reduce recurrence?

• Prompt: What dietary and lifestyle modifications would you recommend?
• Prompt: When should the patient seek medical review?

Q5. What are the red flags for complications requiring urgent intervention?

• Prompt: What systemic signs would indicate possible sepsis?
• Prompt: How would you escalate care if the patient deteriorates?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

A thorough differential diagnosis is essential in this case to distinguish between common anorectal conditions that present with pain, bleeding, and swelling.

Differential Diagnoses:

1. Anal fissure – Classically presents with sharp pain during defecation and bright red rectal bleeding. Chronic fissures may have sentinel tags or hypertrophied anal papillae.
2. Perianal abscess – Typically presents with progressive perianal pain, swelling, and systemic symptoms (fever, malaise). Examination often reveals an erythematous, fluctuant swelling.
3. Thrombosed external haemorrhoid – Presents with sudden-onset painful perianal lump, often after straining or prolonged sitting, with no associated fever or pus.
4. Pilonidal disease – Often involves a midline sinus with purulent discharge, commonly in young males with excessive hair.
5. Crohn’s disease with perianal involvement – Consider if recurrent abscesses or fissures are present, especially if they occur off the midline.

Most Likely Diagnosis:

The patient’s anal pain, bright red rectal bleeding, and visible midline fissure suggest a primary anal fissure. However, the new onset of worsening pain, swelling, erythema, and purulent discharge strongly suggests the development of a secondary perianal abscess, likely originating from an infected anal crypt gland.

Early recognition is crucial, as perianal abscesses can progress to fistula formation or systemic infection if left untreated.

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Q2: What are your immediate management steps?

Answer:

Management focuses on pain relief, infection control, and preventing complications.

1. Pain Management

• Oral analgesia: Paracetamol and ibuprofen are first-line options.
• Topical agents: 2% lidocaine gel may provide temporary relief.
• Stool softeners (e.g., docusate, psyllium husk) – Prevents further trauma to the fissure.

2. Treating the Perianal Abscess

• Incision and drainage (I&D): If abscess is fluctuant and superficial, bedside drainage under local anaesthetic is appropriate.
• Referral to a surgeon: Required if the abscess is large, recurrent, deep, or associated with systemic symptoms.

3. Infection Control

• Antibiotics (e.g., metronidazole + flucloxacillin or amoxicillin/clavulanate) indicated if:
  • Extensive cellulitis is present.
  • The patient is immunocompromised.
  • There is systemic involvement (e.g., fever).

4. Follow-Up & Safety-Netting

• Review in 48 hours to assess healing.
• Educate the patient about worsening symptoms, recurrence, and when to seek urgent care.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation

• “Your symptoms suggest an anal fissure, which is a small tear in the lining of your anus, likely caused by straining.”
• “You also have a perianal abscess, which occurs when a small gland near the anus becomes infected and forms a pocket of pus.”

Management Plan

• “We need to drain the abscess to relieve the pressure and prevent further infection.”
• “Pain can be managed with oral pain relief and topical treatments.”
• “We will also start stool softeners to prevent straining and worsening of the fissure.”
• “If needed, we may use antibiotics.”

Safety-Netting

• “It is important to monitor for increased pain, fever, spreading redness, or difficulty passing stool, as these could indicate a complication.”
• “We will arrange a follow-up in two days to check healing progress.”

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Q4: What preventive measures can help reduce recurrence?

Answer:

• Dietary Modifications:
  • Increase fibre intake (vegetables, whole grains) to prevent constipation.
  • Adequate hydration (2-3 litres/day) to maintain soft stools.
• Hygiene Practices:
  • Warm sitz baths (10–15 min, 2–3 times daily) promote healing and hygiene.
  • Avoid excessive wiping; use moist toilet wipes.
• Regular Bowel Habits:
  • Avoid prolonged straining.
  • Develop a consistent routine for bowel movements.
• Physical Activity:
  • Regular exercise to promote gastrointestinal motility.

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Q5: What are the red flags for complications requiring urgent intervention?

Answer:

• Signs of systemic infection:
  • High fever (>38.5°C), rigors, tachycardia, or hypotension (suggests sepsis).
• Spreading cellulitis:
  • Increasing erythema, warmth, and induration beyond the perianal area.
• Severe perianal pain not improving after drainage.
• Signs of a fistula:
  • Persistent discharge or a non-healing wound.
• Immunocompromised status (e.g., diabetes, chemotherapy) – requires early intervention.

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SUMMARY OF A COMPETENT ANSWER

• Clearly differentiates between anal fissure, perianal abscess, and other anorectal conditions.
• Provides a structured management plan, including pain relief, drainage, and infection control.
• Uses clear and empathetic language to explain the condition and management.
• Recommends appropriate lifestyle and dietary changes to prevent recurrence.
• Recognises red flags and the need for urgent referral if necessary.

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PITFALLS

• Failing to recognise the abscess as a complication of the anal fissure.
• Overlooking systemic signs of infection and not considering sepsis.
• Not adequately explaining the need for drainage and potential recurrence.
• Providing inadequate follow-up or safety-netting advice.
• Misdiagnosing as a thrombosed haemorrhoid and missing the abscess.

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REFERENCES

• RACGP Red Book on Preventive activities in general practice.
• Murtagh’s General Practice, 8th edition on Management of common anorectal conditions.
• Better Health on Management of anal fissures and perianal abscess.
• GP Exams – Anal fissure/perianal abscess

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to anorectal symptoms.
2.2 Performs an appropriate focused examination.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between an anal fissure, perianal abscess, and other anorectal conditions.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides appropriate initial management, including pain relief and stool softeners.
4.2 Recognises when surgical referral is needed.

5. Preventive and Population Health

5.1 Provides education on dietary and lifestyle modifications.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD