Ano-rectal Disorders

Question 1

What are haemorrhoids?

Answer 1

enlarged vascular cushions in the lower rectum and anus

Question 2

What is the lithotomy position?

Answer 2

laid on back, knees bent and raised above the hips - rather like the childbirth position

Question 3

In the lithotomy position, what are the most common locations of haemorrhoids? Why?

Answer 3

3, 7 and 11 o’clock. these are the areas where the 3 major arteries feed vascular plexuses of the anal canal

Question 4

What type of blood appears with haemrrhoids?

Answer 4

bright red

Question 5

Why is there no pain with haemorrhoids?

Answer 5

there are no sensory fibres below the dentate line

Question 6

situation where haemorrhoids might become painful?

Answer 6

if they thrombose and the venous blood cant return

Question 7

what should not be associated with haemorrhoids?

Answer 7

no change in bowel habit or weight loss

Question 8

Causes of haemorrhoids?

Answer 8

constipation with straining is most common. May also be pregnancy, compressing tumours or portal hypertension

Question 9

What are 1st degree haemorrhoids?

Answer 9

remain in the rectum

Question 10

What are 2nd degree haemorrhoids?

Answer 10

prolapse during defecation but spontaneously reduce

Question 11

What are 3rd degree haemorrhoids?

Answer 11

prolapse during defecation but require digital reduction

Question 12

What are 4th degree haemorrhoids?

Answer 12

remain persistently prolapsed

Question 13

Investigations of haemorrhoids?

Answer 13

PR exam, Rigid or flexible sigmoidoscopy, proctoscopy

Question 14

Options for management of symptomatic haemorrhoids?

Answer 14

scleroisation therapy (5% phenol in almond oil), rubber band ligation, open haemmorrhoidectomy, stapled haemorrhoidectomy, HALO (USS identifies supplying artery branches which are stitched off and causes haemorrhoids to shrink)

Question 15

Types of rectal prolapse - which is more common?

Answer 15

partial and complete (more common)

Question 16

what is a partial rectal prolapse?

Answer 16

when the mucosa prolapses

Question 17

What is a complete rectal prolapse?

Answer 17

all layers of the rectum prolapse

Question 18

presentation of a rectal prolapse?

Answer 18

Protruding mass from the anus particularly during defecation that may or may not reduce spontaneously, bleeding and passing mucus from the rectum, examination usually shows poor anal tone

Question 19

For patients too frail for rectal prolapse surgery, what is the management option?

Answer 19

bulking agents and instructions for reduction

Question 20

surgical options for rectal prolapse

Answer 20

perianal rectoplexy, abdominal rectoplexy, derlomes procedure, anterior resection

Question 21

management for incomplete prolapse

Answer 21

dietary advice and scleroisation therapy (5% phenol in almond oil)

Question 22

What is an anal fissure?

Answer 22

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

Question 23

Where may multiple fissures be seen?

Answer 23

in crohns disease

Question 24

What is the presentation of an anal fissure?

Answer 24

acute onset of severe anal pain usually following an episode of constipation. pain lasts for up to half an hour after defecation. bright red rectal bleeding

Question 25

treatment of anal fissures?

Answer 25

dietary advice and stool softeners, pharmacological sphycterotomy (0.3% GTN and 2% diltiazem ointment), botox injection (2nd line with diltiazem), lateral sphyncterotomy

Question 26

What is fistula in ano?

Answer 26

abnormal communication between two epithelial surfaces where there is an internal anal opening and an external

Question 27

investigations of anal fistulas?

Answer 27

Endoanal US, rigid sigmoidoscopy (flexible if frail), protoscopy, MRI

Question 28

Management of anal fistulas?

Answer 28

fistulotomy and excision, seton suture, laid open

Question 29

Complications of anal fistulas?

Answer 29

pain, bleeding, incontinence of flatus or stool, recurrence, further surgery.