Anal Rectal Disorders

Question 1

when do haemorrhoids become palpable on digital examination?

Answer 1

when they are 3rd degree

Question 2

how are haemorrhoids managed?

Answer 2

help symptoms (laxatives etc)
sclerosation therapy (almond oil etc)
rubber band ligation
open haemarrhoidectomy (not common)
stapled haemarrhoidectomy (not common)
HALO/THD procedure (artery ligation - quite common)

Question 3

what are the 2 types of rectal prolapse?

Answer 3

partial (anterior mucosal prolapse)

Complete (full thickness) - common in older females

Question 4

how does prolapse present?

Answer 4

protruding mass from anus (esp. during defaecation) which may reduce spontaneously
bleeding/mucus is common
poor anal tone

Question 5

how is complete prolapse managed?

Answer 5

if too frail for surgery - bulking agent and education on manual reduction
delormes procedure
perineal rectopexy
abdominal rectopexy (if fit)
In children - dietary advice and treat constipation
IN adults - similar to haemorrhoids

Question 6

what is a stoma prolapse?

Answer 6

prolapse of bowel through stoma in the abdomen

Question 7

what is an anal fissure?

Answer 7

tear in anal margin often posterior midline) due to passage of constipated stool

Question 8

what might multiple fissures indicate?

Answer 8

crohns

Question 9

how might anal fissures present?

Answer 9

acute pain like passing “glass” (can last 30 mins after)

bright rectal bleeding

Question 10

what is the dentate? line and why is it significant?

Answer 10

line dividing anal canal
below line = very painful
above line = no pain

Question 11

how are anal fissures treated?

Answer 11

dietary advice, stool softeners
pharmacological sphyncterotomy (GTN or diltiazem ointment)
lateral sphyncterotomy
Botox injection

Question 12

what are fistula in ano?

Answer 12

abnormal communication between 2 epithelial surfaces
internal opening in anal canal and one or more openings on perianal skin
eg. colovescical, colovaginal etc
many fistula - think crohns

Question 13

how will anal fistulas present?

Answer 13

often arise from delay in treatment or inadequate treatment of anorectal abscess
leakage from little opening that doesn’t really heal

Question 14

what underlying disease can cause fistulas?

Answer 14

crohns
TB
carcinoma

Question 15

how are anal fistulae investigated?

Answer 15

EUA of anorectum
rigid sigmoidoscopy, proctoscopy
flexible sigmoidoscopy
MRI (best)

Question 16

how are anal fistulae managed?

Answer 16

laying open
2 stages procedure
insertion of seton string(drainage, cutting)
LIFT procedure
Glue/permacol
defunctioning colostomy

Question 17

what is a fistulotomy?

Answer 17

cut open the fistula and lay it open

Question 18

what are some possible complications of anal fistulae?

Answer 18

pain
bleeding
incontinence of flatus or stool
recurrence (further surgery)

Question 19

what does blood dripping in the toilet indicate?

Answer 19

haemarrhoids

Question 20

what are haemorrhoids?

Answer 20

enlarged vascular cushions in anal canal

Question 21

how do haemorrhoids present?

Answer 21

painless bleeding
fresh, right red blood not mixed with stool often on paper or dripping
perianal itch
no assoc symptoms

Question 22

how is the positioning of haemorrhoids determined?

Answer 22

usually corresponds to branches of superior haemarrhoidal artery:
- 3, 7 and 11 O’ Clock position with patient in lithotomy position

Question 23

how are haemorrhoids investigated?

Answer 23

PR exam
rigid sigmoidoscopy
Proctoscopy
Flexible sigmoidoscopy in patients above 50 yrs