Ano-rectal disorders Flashcards
Define what haemorrhoids are
- Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3 o’clock, 7’o’clock and 11 o’clock respectively).
- Haemorrhoids are said to exist when they become enlarged, congested and symptomatic
What are the clinical features of haemorrhoids ?
- Painless bleeding - Fresh, bright red blood, not mixed with stool, usually on the paper
- Perianal itchiness
- No change in bowel habit, no weigh loss or other associated symptoms
OE:
- External inspection can be normal
- Maceration of the perianal skin
- Obvious haemorrhoids if 3rd degree piles presents
- DRE – normal, internal haemorrhoids are not palpable
What are the 2 main types of haemorrhoids ?
- External = originate above the dentate line. Prone to thrombosis & may be painful
- Internal = orginates below the dentate line. Do not generally cause pain
What are the 4 gradings of haemorrhoids ?
What is the classical positioning of haemorrhoids ?
The classical position of haemorrhoids corresponds to the branches of the superior haemorrhoidal artery occuring at 3 , 7 and 11 o’clock position with the patient in the lithotomy position
What investigations should be done in all patients presenting with PR bleeding ?
- Abdo exam - to rule out other diseases
- DRE - internal haemorrhoids are not palpable
- Proctoscopy - to visualise any internal haemorrhoids
- Rigid sigmoidoscopy - to indntify rectal pathology higher up (do a fexible if patient > 50)
What is shown in the picture
Haemorrhoids - in the classical 3,7&11 o’clock positions
What is the treatment of 1st degree haemorrhoids?
- 1st line = increase fluid & fibre +/- topical analgesics & stool softner (docusate) +/- topical steroids (annusol cream) short term
- 2nd line = Rubber band ligation (superior to sclerotherapy)
What is the treatment of haemorrhoids (worse than 1st degree) ?
- 1st line = Rubber band ligation (superior to sclerotherapy)
- 2nd line = surgery either exicional or stapled haemorrhoidoplexy or doppler guided haemorrhoidal artery ligation (HALO / THD procedure)
How do actuley thrombosed external haemorrhoids present ?
- Painful
- examination reveals a purplish, oedematous, tender subcutaneous perianal mass
What is the treatment of acutely thrombosed external haemorrhoids?
- If patient presents within 72 hours then referral should be considered for excision.
- Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days
What are the 2 types of rectal prolapse ?
- Partial (anterior mucosal prolapse)
- Complete (full thickness)
What are the clinical features of a rectal prolapse ?
- Protruding mass from anus especially during defecation
- Incontinence
- May reduce spontaneously
- Bleeding and passing mucus per rectum is common
- Examination usually shows poor anal tone
What is shown in the pic ?
Rectal prolapse (complete)
What is the treatment of complete rectal prolapses ?
- Many patients too frail for surgery – bulking agent and education on manual reduction
- If not too frail then surgery = Delorme’s procedure or Perineal rectopexy or Abdominal rectopexy or Anterior resection
What is the treatment of incomplete rectal prolapses ?
- In children – dietary advice and treatment of constipation
- In adults – treatment similar to that of haemorrhoids (increase fluid & fibre +/- topical analgesica & stool softner +/- topical steroids short term)
What is an anal fissure and where do they commonly present?
- Tear in the anal margin due to passage of a constipated stool
- Usually in the midline posteriorly at the 12 o’clock position. but may be occasionally anterior
What condition should mutliple anal fissures make you think of ?
Crohn’s disease
How do anal fissures typically present ?
- Acute onset of severe anal pain usually following episode of constipation
- “Glass passing through the back passage”
- Pain lasts for up to ½ h after defecation
- Bright rectal bleeding
What is shown in the pic ?
Anal fissure
What is the treatment of anal fissures ?
- 1st line = increase fibre & fluids + stool softners + lidocaine & GTN ointment or topical diltiazem
- 2nd line = Botox injection + topical dilatiazem
- 3rd line = lateral partial internal sphincterotomy
Define what a fistula is
Abnormal communication between two epithelial surfaces
Define what a fistula in ano is
This is where there is an internal opening in the anal canal with a track communicating to one or more external openings on the peri-anal skin
What are fistula in ano caused by ?
- Perianal abscesses
- Crohn’s disease
- TB
- Diverticular disease
- Rectal carcinoma
