Benign perianal conditions Flashcards
What are the 3 muscles you must try to protect in perianal disease?
Internal and external sphincter
Pelvic floor
What are haemorroids?
Enlarged vascular cushions in the lower rectum and anal canal.
Are haemorroids painful?
Internal = no External = yes
What is the common presentation of haemorroids?
Painless bleeding
Fresh bright red blood, not mixed with stool on the paper.
Perianal itchiness
No change in bowel habit, no weight loss or other associated symptoms.
What are the examination findings of haemorroids?
External inspection can be normal.
Maceration of perianal skin
PR exam normal as you squeeze the blood out of the haemorrhoids, unless thrombosed
What is the classical position of haemorrhoids and why?
3, 7 and 11 O clock as these are the branches of the superior haemorroidal artery
What are the investigationss for haemorrhoids?
PR exam
Proctoscopy
Ridgid sigmoidoscopy
Flexible sigmoidoscopy in patients over 50
What is the treatment for thrombosed haemorroids?
Local anasthetic and cut it to remove the clot
Why do surgeons try to aviod emergency haemorrhoidectomys?
Lots of inflammation and you can’t see the important sphincters.
What is the management of haemorrhoids?
Rubber band ligation
Open haemorroidectomy
Stapled haemorroidectomy (rarely due to tenesumus and strictures in anal canal)
HALO/THD procedure
What is a HALO/THD procedure?
Spinal or general anaesthesia.
Dopler US used in the anal canal to see the blood vessels. Suture the blood vessels supplying the haemorroids.
=> ischemia of haemorroids- pain for 2 weeks. Less pain than open haemorroidectomy.
Can be repeated if bleeding returns.
What are the important points of an open haemorroidectomy?
Open drainage
and leave the skin bridges to allow it to heal. This prevents strictuing of the anal canal.
Are viruses linked to anal cancer?
Yes- HVP virus can preceed anal cancer and intraepithilial dysplasia must be removed.
What are the two types of rectal prolapse?
Partial (anterior mucosal prolapse)
Complete (full thickness)
Why is prolapse more common in women?
Female pelvis is wider. Child birth and hysterectomy allow things to move around in the pelvis
What is the presentation of an anal prolapse?
Protruding mass form anus esp. during defication May reduce spontaneously Bleeding and passing mucus Incontinence PR exam shows poor anal tone
Children get anal prolapse. How is this managed?
Laxatives, fluids.
Due to straining and constipation.
Generally grow out of it.
How is a complete prolapse managed?
To frail for surgery: Bulking agent and education on manual reduction.
Surgery: Delorme’s procedure (short term), Perianal rectopexy (short term), Abdominal rectopexy- involves mesh (long term), Anterior resection (Long term)
How is an incomplete prolapse managed in adults?
Dietary and laxatives.
Surgery similar to haemorrhoids.
How is a prolapsing stoma treated?
Surgically but they often recure
What is an anal fissure?
Tear in the anal margin due to passage of constipated stool. Usually in the midline posteriorly- sentinal tag.
What is multiple fissure suggestive of?
Chron’s disease
Why do anal fissures become chronic?
Tiny painful cut due to passage of hard stools.
Patient afraid of passing stool, too painful, so becomes constipated creating more hard stool generating more fisures
What is the presentation of anal fissures?
Acute onset of anal apin following constipation.
Passing glass through back passage.
Pain lasts fro 30 minutes after defecation
Bright rectal bleeding
WHat is the important of the dentate line?
ANything below the dentate line is very painful- many sensory nerves.
Above there is no pain. Fissures are usually below the dentate line
What is the treatment for fissures?
Dietary advice and stool softeners.
Pharmacological sphincterotomy- (GTN/Diltiazam ointment)
Botox injection.
Why are GTN ointments used in fissures?
Patient keeps anus in muscle spasm and this reduces the blood supply to the fissure preventing healing
GTN will relax the muscles allowing blood suppley to aid healing
What is no longer used for fissures?
Lateral sphyncterotomy or sphincter stretching. High risk of damaging muscles and incontinence.
How does a botox injection work for fissures?
This paralyses the internal anal sphincter, relaxing the muscle allowing blood to flow and the sphincter to heal. This will wear off in 3 months so if any degree of incontinence is created it will resolve in the medium term. Can be repeated
What is an anal fistula?
Abnormal communication between two epithelial surfaces- internal opening in anal canal and one or more external openings on the peri anal skin.
What are the rare causes of anal fistulas?
Chron’s disease, TB or carcinoma
WHat causes most anal fistula?
Delay in treatment or inadequate treatment of anorectal abscesses .
If the abscess drains into the bowel you will develop a fistula because bacteria from the bowel will enter and erode through to the skin
What makes the treatment of anal fistula complicated?
Muscle involvement- sphincter muscles.
Torturous and branching course
What are the investigations for anal fistula?
Examination of rectum
Rigid sigmoidoscopy or proctoscopy- can you see an internal opening
MRI- most information about path of fistula (not normally straight!
What is the management of anal fistula?
Laying open. Cut the fistula open.
Drainage- insertion of a Seton stitch and allowing drainage so it doesn’t heal from the bottom and fill with pus.
LIFT procedure
Glue/permacol
Defunctioning colostomy if cannot resolve
What are the complications of fistula operations?
Pain Bleeding Incontinence of flatus or stool Recurrence Further surgery.
