Ano-rectal disorders

Question 1

What are haemorrhoids?

Answer 1

Enlarged vascular cushions in the lower rectum and anal canal

Question 2

What is the presentation of haemorrhoids?

Answer 2

Painless bleeding
Fresh, bright red blood, not mixed, usually on paper
Perianal itchiness

No change in bowel habit, no weight loss or other assoc symptoms

Question 3

What clinical findings might you see in haemorrhoids?

Answer 3

External inspection might be normal

Maceration of the perianal skin

Obvious if the haemorrhoids are 3rd degree - piles present

Question 4

Where are the classical position of haemorrhoids?

Answer 4

Correspond to the branches of the superior haemorrhoidal artery

• occurring at 3, 7 and 11 o’clock

Question 5

What investigations might you do for someone with haemorrhoids?

Answer 5

PR exam
Rigid sigmoid
Proctoscopy
Flexible sigmoid in patients above 50

Question 6

How do you treat/manage haemorrhoids?

Answer 6

Symptomatic

Sclerosation therapy with 5% phenol in almond oil
Rubber band ligation
Open haemorrhoidectomy
Stapled haemorrhoidectomy

HALO/THD procedure

Question 7

What is the HALO/TDH procedure?

Answer 7

Hemorrhoidal artery ligation

Mini doppler ultrasound device locates branches of arteries supplying the haemorrhoids. Blood vessels tied off and haemorrhoids shrink over days and weeks.

(Pain free as stitch is placed in lower rectum where virtually no sensory nerves)

Question 8

What 2 kinds of rectal prolapse can you get?

Answer 8

Partial - anterior mucosal prolapse

Complete - full thickness

Question 9

What is the presentation of rectal prolapse?

Answer 9

Protruding mass from anus - especially during defecation

May reduce spontaneously
Bleeding and passing mucus per rectum - common
Examination - shows poor anal tone

Question 10

What is the management of complete prolapse?

Answer 10

Most patients too frail for surgery - bulking agents and education on manual reduction

Delormes prcedure
Perineal rectopexy
Abdominal rectopexy
Anterior resection

Question 11

What is the management of incomplete prolapse?

Answer 11

Children - diet advice and constipation treatment

Adults - similar to haemorrhoids treatment

Question 12

What is an anal fissure?

Answer 12

Tear in the anal margin due to passage of a constipated stool

Question 13

Where do you usually find the anal fissure?

Answer 13

In the midline posteriorly but may be occasionally anterior

Question 14

What might multiple fissures be due to?

Answer 14

Crohns disease

Question 15

What is the presentation of anal fissures?

Answer 15

Acute onset of severe anal pain usually following episode of constipation

Glass passing through the back passage

Pain lasts for up to 1/2 hour after defecation

Bright rectal bleeding

Question 16

What is the treatment of anal fissures?

Answer 16

Stool softener and it advice

Pharmacological sphycterotcomy (diltiazem ointment)
Lateral sphyncterotomy
Botox injection

Question 17

What is a fistula in ano?

Answer 17

Abnormal communication between 2 epithelial surfaces

There is an internal opening in the anal canal and one or more external openings on the peri-anal skin

Question 18

What might the presentation of fistula in ano be?

Answer 18

Most arise from delay in treatment or inadequate treatment of anorectal abscesses

Question 19

What investigations might you do for fistula in ano?

Answer 19

EUA of anorectic
Rigid sigmoidoscopy, proctoscopy
Flexible sigmoidoscopy
MRI

Question 20

What is the management of fistula in ano?

Answer 20

Laying open
2 stage procedure
Inception of seton (draining and cutting)
LIFT procedure 
Glue/permacol 
Defunctioning colostomy

Question 21

What are some complications of fistula in ano?

Answer 21

Pain 
Bleeding 
Incontience of flatus or stool 
Recurrence 
Further surgery