Ano-Rectal Disorders

Question 1

Define Haemorrhoids

Answer 1

Enlarged vascular cushions in the lower rectum and anal canal

Question 2

What percentage of the population will have symptomatic haemorrhoids at some point in their life?

Answer 2

10%

Question 3

What are the 3 components of haemorrhoid presentation?

Answer 3

Normally painless bleeding (can be some discomfort)
Perianal itchiness
No other associated symptoms (weight loss, change in bowel habits etc)

Question 4

Describe the bleeding from haemorrhoids

Answer 4

Fresh, bright red blood on the paper or around the surface of the stool

Question 5

What are the 2 possible findings upon PR inspection of haemorrhoids?

Answer 5

Normal

Softening of perianal skin

Question 6

What is the normal PR finding for haemorrhoids?

Answer 6

Nothing (unless thrombosed)

Question 7

What are the 3 classic locations of haemorrhoids?

Answer 7

3, 7 and 11 o’clock in the lithotomy position

Question 8

What are the 4 investigations that should be done to a patient presenting with haemorrhoids?

Answer 8

PR exam (exclude cancer)
Rigid sigmoidoscopy
Proctoscopy
Flexible sigmoidoscopy

Question 9

What patients presenting with haemorrhoids should be given a flexible sigmoidoscopy and why?

Answer 9

Those over 50 y/o to exclude cancer

Question 10

What is a primary haemorrhoid?

Answer 10

Internal

Question 11

What is a second degree haemorrhoid?

Answer 11

Prolapsing

Question 12

What is a third degree haemorrhoid?

Answer 12

Prolapsed

Question 13

What is the management of haemorrhoids based on?

Answer 13

Symptoms

Question 14

If haemorrhoids have very little/no symptoms, what should be done? (2)

Answer 14

No treatment

Constipation relief/advice

Question 15

What is the best method for treating hemorrhoids?

Answer 15

HALO procedure

Question 16

What does the HALO procedure involve?

Answer 16

Using a doppler to identify the blood vessels supplying the haemorrhoid and ligating them

Question 17

What are the 4 treatments that can be given for haemorrhoids instead of the HALO procedure?

Answer 17

Sclerosation therapy
Rubber band ligation
Open/stapled haemorrhoidectomy
Suppositories containing local anaesthetic and corticosteroids

Question 18

What is the purpose of sclerosation therapy in haemorrhoids?

Answer 18

Thicken blood vessels

is painful and outdated

Question 19

What is a patient left with after a open haemorrhoidectomy?

Answer 19

An open wound that takes 6-8 weeks to heal

Question 20

What group of people do you have to be cautious about when considering an open haemorrhoidectomy and why?

Answer 20

Women - need to make sure you dont damage the pelvic floor

Question 21

What can some patients be left with after a stapled haemorrhoidectomy?

Answer 21

A feeling of urgency

Question 22

What is a partial rectal prolapse?

Answer 22

Just the anterior mucosa prolapsing

Question 23

What is a complete rectal prolapse?

Answer 23

All the bowel layers prolapsing

Question 24

What is the typical rectal prolapse patient?

Answer 24

Older women with kids

Question 25

Prolapses tend to be (recurrent/one offs)

Answer 25

Recurrent

Question 26

What are the 2 main presentations of a rectal prolapse?

Answer 26

Protruding mass from the anus, especially during defecation | Bleeding and mucus PR

Question 27

Why does a rectal prolapse become ulcerated?

Answer 27

If it is left outside the body for a while

Question 28

What is apparent on a PR examination of a rectal prolapse patient?

Answer 28

Poor anal sphincter tone

Question 29

What is the gold standard management for a complete prolapse?

Answer 29

Perineal rectopexy

Question 30

Many rectal prolapse patients are too frail for surgery. What is the alternative treatment given to these patients?

Answer 30

Bulking agents and education for manual reduction

Question 31

What is the management for children with incomplete rectal prolapses?

Answer 31

Dietary advice and constipation treatment

Question 32

What is the management for adults with incomplete rectal prolapses?

Answer 32

Similar to that of haemorrhoids

Question 33

Define an anal fissure

Answer 33

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

Question 34

Normally, where does an anal fissure occur?

Answer 34

In the midline, posteriorly

Question 35

What bowel disease can cause multiple anal fissures?

Answer 35

Crohn's

Question 36

What are the 2 presentations of anal fissures?

Answer 36

Pain after defecation (lasts about 1/2 hour) | Bright blood PR

Question 37

Why does anal fissure pain last so long?

Answer 37

Sphincter spasm

Question 38

What is the primary treatment for anal fissures?

Answer 38

Dietary advice and stool softeners

Question 39

What does treatment of an anal fissure via a pharmacological sphincterotomy involve?

Answer 39

GTN and diltiazem ointment | 6 weeks

Question 40

During botox injections for anal fissures, what is paralysed?

Answer 40

Internal anal sphincter

Question 41

How long does botox treatment for an anal fissure last?

Answer 41

3 months

Question 42

How does botox work to treat anal fissures?

Answer 42

Relaxes the sphincter, therefore opening the blood vessels and allowing blood to flow

Question 43

If pharmaceutical intervention does not help treat an anal fissure, what should be done?

Answer 43

Surgery - lateral sphincterectomy

Question 44

Define a fistula

Answer 44

Abnormal connection between 2 epithelial surfaces

Question 45

What is an anal fistula normally caused by?

Answer 45

An abscess that is not treated, therefore growing and bursting either internally or externally

Question 46

What are the 3 rarer (systemic) causes of anal fistulas?

Answer 46

Crohn's TB Cancer

Question 47

What are the 4 investigations for an anal fistula?

Answer 47

Endoanal ultrasound Rigid/flexible sigmoidoscopy MRI Proctoscopy

Question 48

What 3 things should you aim to identify during the investigations of an anal fistula?

Answer 48

Primary and secondary tracts Exclude sepsis Identify any underlying diseases

Question 49

What does the treatment of an anal fistula normally involve?

Answer 49

Draining and cutting open the anal fistula and then allowing it to heal

Question 50

What are the key questions to ask in a history about anorectal diseases? (6)

Answer 50

``` Symptom duration First episode or recurrence Bleeding (type and association with stool) Pain Any protrusions Any associated discharge ```