Benign Perianal conditions

Question 1

define haemorrhoids

Answer 1

abnormal enlargements of the anal cushions which normally function to maintain faecal continence
high pressure reduces venous outflow and causes prolapse

Question 2

2 most common symptoms of uncomplicated piles?

Answer 2

bleeding- bright red, usually after defecation
palpable lump or sensation of something coming out of the anus (prolapse) after defecation

if they cause a mucous discharge from exposed mucosa, this may result in pruritus ani.
can get bloating as gas formed due to stools stuck.

Question 3

when are piles painful?

Answer 3

only when there are complications. becomes tense, hard and oedematous if SM vessels thrombose, so defecation then painful.

Question 4

rectal bleeding, but no anal pain, differentials?

Answer 4

blood after defecation= haemorrhoids
blood and mucus= colitis
blood and looser stool= colorectal carcinoma

blood alone= diverticular disease or angiodysplasia
malaena= peptic ulceration

Question 5

rectal bleeding and anal pain differentials?

Answer 5

fissure

anal canal carcinoma

Question 6

Tments for haemorrhoids?

Answer 6

increase fibre and fluids in diet, fruit juice-more oncotic avoid straining, regulate bowel movements- empty bowels in a regular pattern
fibre supplement
rubber band ligation- only for internal haemorrhoids, cut off b.flow
injection sclerotherapy
infrared photocoagulation
haemorrhoidectomy- very painful!, or stitches in piles
can do teardrop excision if external

Question 7

define a fissure-in-ano

Answer 7

ulcer in skin of anal canal, longitudinal tear in anoderm

located in mid-line

Question 8

describe the tearing-pain-spasm sequence of anal fissures

Answer 8

an acute tear fairly common in those with constipation- creates high pressure at anal canal as forceful defecation, but tends to heal quickly. Tear may however reopen on next defecation, causing further pain, which increases anal sphincter tone causing spasm, increasing likelihood of tear opening again on next defecation, and reducing blood supply so healing is inadequate, again allowing tear to open again.
base then becomes fibrous and doesn’t heal, so fissure becomes chronic.

Question 9

how are haemorrhoids investigated to exclude other differentials?

Answer 9

proctoscopy and sigmoidoscopy- exclude colitis- blood and mucus, and colorectal carcinoma- blood and loose stools.

Question 10

symptoms of anal fissures?

Answer 10

PAIN- begins during defecation, tearing sensation, excruciating, post defecation stinging. ‘like pooing glass’
pain can persist for hrs with chronic fissure.
may then avoid defecation, so large hard mass of faeces produced which makes pain worse on nxt defecation. Also more difficult to pass stool due to spasm.

stools streaked with blood, and blood stains toilet paper
TOO PAINFUL for sigmoidoscopy or proctoscopy in conscious ptnt.

Question 11

tment for fissure-in-ano?

Answer 11

condition either heals or becomes chronic
counselling- keep motions soft- fibre e.g. oats, porridge, fruit juice, and increase fluids, laxatives e.g. lactulose
creams- GTN or diltiazem relax muscle so blood supply increased to aid healing. Nitrates increase b.supply, and Ca2+ blockers rrelax IS to increase blood supply and allow healing.
may do EUA as don’t want to miss a lower rectal/anal cancer
keep skin dry and clean if pruritis ani from wiping too hard post def.

other options= botox- relax internal sphincter, injected into intersphincteric sphincteric space at 3 and 9 o clock.
lateral internal sphincterotomy- would be unsuitable in women as sphincter already weakened by pregnancy and after childbirth. Done at 3oclock position. RISK= incontinence.

Question 12

Patients at risk of perianal sepsis?

Answer 12

immunocompromised e.g. on steroids, biologics
diabetics
obese
older

perianal abscesses- DM, crohn’s, malignancy

Question 13

how does a perianal abscess form?

Answer 13

*cryptoglandular theory
anal gland (cryptogland) infection-gland blocked, pus tracks down to perineum between sphincters to form abscess, can penetrate external sphincter to reach ischio-rectal fossa to form an abscess here aswell.
If secretion by anal gland continues, a fistula can develop.

Question 14

most common symptom of an anal fistula?

Answer 14

watery or purulent discharge from external opening
may be recurrent episodes of pain

often occurs in ptnts with crohn’s disease

Question 15

tment of an anal fistula?

Answer 15

lay it open- insert probe and cut down onto it. Opens up tract so can be flushed out and left to heal. Can lead to incontinence.
seton- piece of surgical thread left in fistula opening to allow it to drain properly before healing.

Question 16

symptoms and signs of a vesical fistula?

Answer 16

frequent UTIs

air when go to toilet

Question 17

describe a pilonidal sinus

Answer 17

nest of hairs
in midline skin of natal cleft, between coccyx and anus
lined by granulation tissue
hairs acts as FBs when infection develops, so chronic abscess develops. Hair growth causes inflammation.
pits/sepsis areas

symptoms- pain and swelling in natal cleft, purulent discharge if infected
skin red and tender over sinus

treat- can excise all tracts

Question 18

what are anal cushions?

Answer 18

venous dilatations formed in the anal canal SM, surrounded by smooth muscle, elastic and fibrous tissue, and overlying mucosa. SM smooth muscles anchored to internal sphincter and longitudinal muscle passing through IS fasciculi.
they temporarily are displaced downwards in defecation.
constipation and straining raise pressure, disrupting firomuscular support network so they can slide downwards and SM vessels engorge as they prolapse.
network returns anal canal to its initial position following defecation.

Question 19

where are the 3 main anal cushions found?

Answer 19

left lateral, right posterior and right anterior positions.
(3, 7 and 11 o’clock positions).
this is when patient is in the supine lithotomy position.

Question 20

why must botulinum toxin NOT be injected into internal sphincter smooth muscle?

Answer 20

can result in a haematoma forming

Question 21

where does an anal fissure most commonly appear?

Answer 21

12 or 6 o clock positions

Question 22

classification of haemorrhoids by degree of prolapse and for tment purposes?

Answer 22

graded 1-4
1st degree= project into lumen during straining, but don’t prolapse
2nd= prolapse during defecation then spontaneously reduce
3rd= prolapse during defecation but require manual reduction
4th= prolapsed irreducible haemorrhoids

Question 23

contrast hamorrhoids and rectal varices

Answer 23

haemorrhoids= prolapsed venous dilatations of the anal submucosa that occurs with constipation and straining.
rectal varices= portosystemic collateral veins that develop with PH e.g. in liver cirrhosis. Collateral flow between superior rectal vein of portal circul. and middle and inferior rectal veins of systemic circul.

Question 24

complications post-op to warn a ptnt of before laying open of an anal fistula, with/without a seton?

Answer 24

infection
haemorrhage
recurrence
incontinence
anal scarring/fibrosis?
chest infection
thrombotic disease

Question 25

why are anal fissures more common in young people?

Answer 25

poor diet- lack of fibre necessary to prevent constipation and so forceful defecation

Question 26

skin assoc with anal fissures may form what?

Answer 26

sentinel tags- torn from base of fissure

Question 27

why is defecation incomplete with an anal fissure, which must be distinguished from tenesmus seen with rectal cancers?

Answer 27

internal sphincter closes rapidly due to pain stimulus

Question 28

describe the internal anal sphincter

Answer 28

continuation of rectal circular smooth muscle
involuntary control, contracted during rest, relaxes on defecation
appears grey

Question 29

describe the external anal sphincter

Answer 29

voluntary striated muscle
pudendal nerve, S2-S4
appears red

Question 30

ADRs of Ca2+ blockers?

Answer 30

headaches

fainting

Question 31

why might ptnt have fragmented stools?

Answer 31

constipation as result of dehydration

stool contracts with fluid lack, and these stools increase pressure increasing risk of haemorrhoids, as harder to pass.

Question 32

why is muco-cutaneous bridge necessary in haemorrhoidectomy?

Answer 32

stop anal canal stenosis

Question 33

importance of metronidazole use in colrectal surgery?

Answer 33

antibiotic prophylaxis but also deals with free O2 radicals produced in surgical wounds e.g. from use of diathermy

Question 34

tment of thrombosed haemorrhoids?

Answer 34

ice packs- reduce swelling
analgesia
stool softeners
bed rest-raise foot of bed
then re-assess for banding or haemorrhoidectomy

Question 35

define abscess

Answer 35

pus contained in a cavity lined by a pyogenic membrane which antibiotics are unable to cross, so requires drainage

Question 36

define sinus

Answer 36

a blind ended tract lined by epithelia, formed when abscess bursts onto skin surface

Question 37

recurrence rate of anal fistulae?

Answer 37

50% due to missed secondary tracts

Question 38

importance of perianal abscess detection in diabetic ptnt?

Answer 38

quick progression to necrotising fascitis

Question 39

acute presentation of perianal abscess?

Answer 39

lump- throbbing pain
fever
constitutional upset

Question 40

probe used in perianal abscess drainage?

Answer 40

lockart’s probe
need incision and drainage
and then packing of wound, must heal from bottom upwards

Question 41

classification of anal fistulae?

Answer 41

intersphincteric- primary internal opening on dentate line, runs through IS then between I and E to open on perineal skin.
transphincteric- primary internal opening on dentate line, runs through both I and E Ss into IR fossa and then perineal skin.
suprasphincteric- primary internal opening on dentate line, runs through IS then uwards intersphincterically and discharges through L ani inti IR fossa and then perineal skin. tract curves above puborectalis sling.
extrasphincteric- internal opening above levators, track runs external to external sphincter.

Question 42

how is the rectum above demarcated from the anal canal below?

Answer 42

by the anorectal ring/flexure where the puborectalis muscle forms a sling around the posterior aspect of the anorectal junction

Question 43

embryological origin above and below pectinate/dentate line?

Answer 43

above= hindgut endoderm
below= proctodeum (ectoderm)

Question 44

position of internal opening of anal fistulae, considering goodsall’s rule, if external opening is posterior to line between the 2 ischial tuberosities?

Answer 44

6 o clock position

Question 45

why is a seton suture, tightened over time, used for high anal fistulae?

Answer 45

to maintain continence due to involvement of continence muscles of anus