Benign Anorectal/perianal Conditions

Question 1

Define haemorrhoids

Answer 1

Abnormal swelling or enlargement of Anal vascular cushions.
Clusters of vascular tissue , smooth muscle of treitz, connective tissue lined by normal epithelium of anal canal.
Haemorhoidal bleeding = arterial!

Question 2

Location of anal cushions?

Answer 2

3,7 and 11 o clock position in lithotomy position

Question 3

External vs internal haemorrhoids? (Origin, location, innervation, pain, venous drainage)

Answer 3

• Ectoderm (stratified squamous epithelium) VS endoderm (columnar epithelium of anal mucosa)
. Below pectinate line vs above
• somatic innovation (inferior rectal nerve) VS autonomic nervous system (not sensitive to pin prick)
• may thrombose causing pain and itching, secondary scarring may lead to skin tags VS perianal pain by prolapsing and causing spasm of sphincter complex around haemorrhoids, acute pain when incarcerated or strangulated
• inferior rectal vein → IVC vs superior rectal vein → portal venous system
(rich anastomosis exist between these 2 and middle rectal vein)

Question 4

Classification of haemorrhoids?

Answer 4

Goligher classification
Grade 1: does not prolapse
Grade 2: prolapse and reduce spontaneously
Grade 3: prolapse and need manual reduction
Grade 4: prolapse and irreducible

Question 5

General Clinical presentation haemorrhoids? (5)

Answer 5

• Rectal bleeding - painless, fresh, coating / dripping, not mixed with stool
• pain
• mucous discharge
• pruritis
• prolapse

Question 6

Clinical presentation internal haemorrhoids (5)

Answer 6

• Swelling → dilatation and engorgement arteriovenous plexuses → stretching suspensory muscles and eventual prolapse
• engorged Anal mucosa easily traumatised → red rectal bleeding due to high blood oxygen content within av anastomoses.
• prolapse → soiling and mucous. discharge (triggering pruritis) predisposing to incarceration and strangulation

Question 7

Clinical presentation external haemorrhoids (3)

Answer 7

• Acute thrombosis: after physical exertion, straining, bout of diarrhoea, change in diet… Pain from rapid distension innervated skin by the clot and surrounding oedema lasting 7-14 days
• erode overlying skin and cause bleeding

Question 8

Name 5 complications haemorrhoids

Answer 8

• Strangulation and thrombosis
• Ulceration
• gangrene
• sepsis
• fibrosis

Question 9

Management grade 1 haemorrhoids? (6)

Answer 9

First line
• Lifestyle: avoid straining during defacation
. Diet: high fibre, increase water,
• stool softener

Second line: surgery - targeted at origin of cushion without excision. Options:
• rubber band ligation
• sclerosing injection
• infrared coagulation
• diathermy coagulation
• cryotherapy

Question 10

Treatment acutely thrombosed external haemorrhoids? (2)

Answer 10

<24 hours: treat by surgical excision of thrombosed Vein outside mucocutaneous junction with wound left open
>48 hours: non-surgical symptomatic management

Question 11

Management grade 2 haemarrhoids (7)

Answer 11

First line = lifestyle, diet, stool softeners

Second line = surgery
• rubber band ligation
• sclerosing injection
• infrared coagulation
• diathermy coagulation
• cryotherapy
• Doppler guided haemarrhoid artery ligation (Hal)

Question 12

Management grade 3 haemarrhoids (5)

Answer 12

Surgical as for grade 2. If these fail:

• milligan-morgan (open) haemorrhoidectomy
• Ferguson (closed) haemorrhoidectomy
• ‘ Park’s operation (submucosal reconstruction haemorrhoidectomy)
• radio frequency ablation

Question 13

Management grade 4 haemorrhoids

Answer 13

Longo stapled haemorrhoidopexy (anopexy)

Question 14

Define Anal fissure

Answer 14

Split in anoderm

Question 15

Etiology anal fissure? (6)

Answer 15

• Acute by mechanical force generated by passage of large, hard stool through anal canal that’s too small to accommodate it

Secondary causes:
• Chron’s disease (fissure lateral position)
• extra-pulmonary Tb
• Anal ScC
• anorectal fistula
• infections: CMV, hsv, chlamydia, syphilis

Question 16

Where do AnaI fissures occur?

Answer 16

•90% posterior Anal midline
• 10% anterior
• lateral associated with other secondary causes

Question 17

Clinical presentation Anal fissures? (8)

Answer 17

• Tearing pain with defecation
• severe anal spasms that last for hours after
• bright Pr bleed
• perianal pruritis and or skin irritation

• unable to tolerate Dre
• chronic = hypertrophied boat shaped and punched out exposing internal sphincter with sentinel skin tag and or hypertrophic Anal papilla

Question 18

Management Anal fissures? (8)

Answer 18

• if presenting rectal bleeding. Must be offered colonoscopy
• 90% heal with medical treatment, because of good blood supply, in 1-2 days:
- lifestyle modifications (increased fibre)
- sitz baths
- topical nifedipine ointment (CCB reduce resting anal pressure)
- GTN (glyceryl trinitrate relax mm) paste bd 2/12 or diltiazem 2%
- botulinum toxoid injection
• if don’t heal, due to spasm internal sphincter. Surgery:
- lateral internal sphincterotomy 90% successful
- anal advancement flap for low rectal pressure for female post partum or male previous anal surgery

Question 19

Etiology and classification anorectal abscesses? (6)

Answer 19

• Most cryptogenic origin
• begin as infections in anal glands in intersphincteric space that empty into anal crypts at dentate line ; ducts of these glands become obstructed by faeces
• secondary infection develop resulting in anorectal abscess.
• other causes = Chrons, hidradenitis suppurativa
• infection may extend vertical (perianal 60% or supralevator 4%), horizontally (ischiorectal 20%) or circumferential (horseshoe) , intersphincter 5%
• common bacterial = e coli, staphylococcus

Question 20

Clinical presentation and symptoms anorectal abscesses? (3)

Answer 20

• Pain in perianal area- dull, aching or throbbing, worse on sitting down and right before bowel movement
• examination= small, erythematous, well-defined, fluctuant, subcutaneous mass near anal orifice
• more common in immunocompr

Question 21

Treatment anorectal abscesses? (6)

Answer 21

• Surgical drainage
- intersphincteric and submucosal drained into anal canal
- ischiorectal via pyramidal skin incision
- horseshoe drain bilateral cutaneous incisions to address ischiorectal component
- supralevator: CT abdomen to exclude aetiology, drain into rectum/anal canal or may need laparotomy, re-image if persistently pyrexia post drainage
•Antibiotics only if immunocomprised, extensive cellulitis, valvular heart disease
• post-op: analgesics, stool bulking agents, stool softeners, daily antiseptic sits bath

Question 22

Name 2 complications anorectal abscesses

Answer 22

• Sepsis: necrotising fasciitis
• anal fistula- 40% develop chronic fistula

Question 23

Name 9 causes/risk factors perianal fistula

Answer 23

Medical and surgical conditions
• Usually associated with anorectal abscess, develop in 1/3 patients who undergo drainage
• Chron ‘s disease
• neoplasm
• hidradenitis suppurativa

Infections
• Tb
• fungal infection
• actinomycosis

Trauma
• trauma and foreign body perforation

Host
• 3rd-5th decade life

Question 24

Clinical features and history perianal fistula? (2)

Answer 24

• Intermittent purulent discharge, may have bleeding
• pain which increases until temporary relief with pus discharge

Question 25

What is Goodsall’s rule?

Answer 25

For fistula with external opening within 3 cm of the anal verge and posterior to line drawn through ischial spines if
• anterior to transverse anal line: internal opening straight radially directed tract into anal canal
• post to transverse anal line: curve tract open into anal canal midline posteriorly at level of dentate line

Question 26

Investigations for perianal fistula? (3)

Answer 26

• Endoanal ultrasound (water aided for hyperechoic effect) to view course of fistula tract
• MRI: able to visualise entire pelvis, beyond sphincter complex. Gold standard
• CT / fistulography in emergency situation for complex fistula / unusual anatomy

Question 27

Classification of anal fistula? (5)

Answer 27

Parks classification
1. Intersphincteric (45 %) - exit through intersphincteric plane therefore doesn’t involve external sphincter.
2. Trans-sphincteric (30%) - low (distal 1/3 external sphincter) vs high (involve more, can cause incontinence if divided)
3. Supra-sphincheric (20%) - exit onto skin in ischiorectal fossa.
4. Extra sphinceric- rare
5. Submucosal

Question 28

Treatment low anal fistula?

Answer 28

Lay open with fistulotomy (preferred. cut and lay open tract to heal - grooved probe passed from external to internal track and laid open over probe. Track curetted to remove granulation tissue, edges of wound trimmed. Wound may then be mursupialised) or fistulectomy (coring out with diathermy cautery, remove entirely)

Question 29

Treatment high anal fistula?

Answer 29

Require 2 stage surgery.

Question 30

Which muscle must be preserved during fistulectomy and why?

Answer 30

Puborectalis is key to future continence

Question 31

Which surgical technique is used for complex, long, high anal tracts?. (2)

Answer 31

Seton
• run surgical grade cord through fistula tract so that cord creates loop that joins up outside fistula.
• allow fistula to drain continuously while it’s healing, rather than allowing exterior of wound to close over
• seton can be tied loosely:long term palliation, temporary before surgical treatment like fistulotomy, fistulectomy)
• or can be tied tightly: cut through tissue inside loop while scarring behind loop, ie pull out fistula without surgery

Or advancement flap

Question 32

Treatment Chron’s fistula?

Answer 32

• Infliximab once perianal sepsis controlled
• fistula chronic drainage with non-cutting setons

Question 33

Define pilonidal disease

Answer 33

Hair- containing sinus or abscess which involves skin and subcutaneous tissues in post sacral, inter gluteal region. More common in hirsutism

Question 34

3 theories of pathogenesis of pilonidal disease

Answer 34

Congenital
• persistence medullary ridge

Acquired
• hairs,due to anatomy and motion of buttocks, propelled through skin then act as nidus for infection.
• enlarged hair follicle becomes blocked and infected, forming abscess

Question 35

Management pilonidal disease?

Answer 35

•Complete excision and heal with granulation or primary closure or advancement flap
• shave local skin weekly to prevent reintroduction of hair

Question 36

Define hidradenitis suppurativa and etiology

Answer 36

• Chronic inflammatory process affecting apocrine glands of perianal region characterised by abscess and sinus formation. Result of keratotic debris plugging apocrine gland
• strep milleri, S aureus, S epidermis, staph hominis = common bacterial organisms
• numerous fistulas readily identified

Question 37

Treatment hidradenitis suppurativa? (3)

Answer 37

•exclude coexisting cancer with biopsy
• oral antibiotics, usually erythromycin
• wide excision with skin graft

Question 38

Identify pathology picture 35

Answer 38

Grade 1 haemorrhoids

Question 39

Identify pathology picture 36

Answer 39

Grade 2 -4 haemorrhoids, depending on whether it is reducible, spontaneously or manually.

Question 40

Identify pathology picture 37

Answer 40

Grade 4 haemorrhoids

Question 41

Label the areas of potential anorectal abscesses on picture 38

Answer 41

See picture 39

Question 42

Classify the anorectal fistula seen on picture 40

Answer 42

Intersphincteric
Through internal sphincter only

Question 43

Classify the anorectal fistula seen on picture 41

Answer 43

Trans-sphinctenic

Question 44

Classify the anorectal fistula seen on picture 42

Answer 44

Supra sphincteric

Question 45

Classify the anorectal fistula seen on picture 43

Answer 45

Extrasphincteric