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Benign perianal conditions Flashcards

1
Q

What are the 3 muscles you must try to protect in perianal disease?

A

Internal and external sphincter

Pelvic floor

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2
Q

What are haemorroids?

A

Enlarged vascular cushions in the lower rectum and anal canal.

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3
Q

Are haemorroids painful?

A 
Internal = no
External = yes
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4
Q

What is the common presentation of haemorroids?

A

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.

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5
Q

What are the examination findings of haemorroids?

A

External inspection can be normal.
Maceration of perianal skin
PR exam normal as you squeeze the blood out of the haemorrhoids, unless thrombosed

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6
Q

What is the classical position of haemorrhoids and why?

A

3, 7 and 11 O clock as these are the branches of the superior haemorroidal artery

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7
Q

What are the investigationss for haemorrhoids?

A

PR exam
Proctoscopy
Ridgid sigmoidoscopy
Flexible sigmoidoscopy in patients over 50

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8
Q

What is the treatment for thrombosed haemorroids?

A

Local anasthetic and cut it to remove the clot

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9
Q

Why do surgeons try to aviod emergency haemorrhoidectomys?

A

Lots of inflammation and you can’t see the important sphincters.

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10
Q

What is the management of haemorrhoids?

A

Rubber band ligation
Open haemorroidectomy
Stapled haemorroidectomy (rarely due to tenesumus and strictures in anal canal)
HALO/THD procedure

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11
Q

What is a HALO/THD procedure?

A

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.

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12
Q

What are the important points of an open haemorroidectomy?

A

Open drainage

and leave the skin bridges to allow it to heal. This prevents strictuing of the anal canal.

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13
Q

Are viruses linked to anal cancer?

A

Yes- HVP virus can preceed anal cancer and intraepithilial dysplasia must be removed.

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14
Q

What are the two types of rectal prolapse?

A

Partial (anterior mucosal prolapse)

Complete (full thickness)

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15
Q

Why is prolapse more common in women?

A

Female pelvis is wider. Child birth and hysterectomy allow things to move around in the pelvis

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16
Q

What is the presentation of an anal prolapse?

A 
Protruding mass form anus esp. during defication
May reduce spontaneously
Bleeding and passing mucus
Incontinence
PR exam shows poor anal tone
17
Q

Children get anal prolapse. How is this managed?

A

Laxatives, fluids.
Due to straining and constipation.
Generally grow out of it.

18
Q

How is a complete prolapse managed?

A

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)

19
Q

How is an incomplete prolapse managed in adults?

A

Dietary and laxatives.

Surgery similar to haemorrhoids.

20
Q

How is a prolapsing stoma treated?

A

Surgically but they often recure

21
Q

What is an anal fissure?

A

Tear in the anal margin due to passage of constipated stool. Usually in the midline posteriorly- sentinal tag.

22
Q

What is multiple fissure suggestive of?

A

Chron’s disease

23
Q

Why do anal fissures become chronic?

A

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

24
Q

What is the presentation of anal fissures?

A

Acute onset of anal apin following constipation.
Passing glass through back passage.
Pain lasts fro 30 minutes after defecation
Bright rectal bleeding

25
Q

WHat is the important of the dentate line?

A

ANything below the dentate line is very painful- many sensory nerves.
Above there is no pain. Fissures are usually below the dentate line

26
Q

What is the treatment for fissures?

A

Dietary advice and stool softeners.
Pharmacological sphincterotomy- (GTN/Diltiazam ointment)
Botox injection.

27
Q

Why are GTN ointments used in fissures?

A

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

28
Q

What is no longer used for fissures?

A

Lateral sphyncterotomy or sphincter stretching. High risk of damaging muscles and incontinence.

29
Q

How does a botox injection work for fissures?

A

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

30
Q

What is an anal fistula?

A

Abnormal communication between two epithelial surfaces- internal opening in anal canal and one or more external openings on the peri anal skin.

31
Q

What are the rare causes of anal fistulas?

A

Chron’s disease, TB or carcinoma

32
Q

WHat causes most anal fistula?

A

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

33
Q

What makes the treatment of anal fistula complicated?

A

Muscle involvement- sphincter muscles.

Torturous and branching course

34
Q

What are the investigations for anal fistula?

A

Examination of rectum
Rigid sigmoidoscopy or proctoscopy- can you see an internal opening
MRI- most information about path of fistula (not normally straight!

35
Q

What is the management of anal fistula?

A

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

36
Q

What are the complications of fistula operations?

A 
Pain
Bleeding 
Incontinence of flatus or stool
Recurrence
Further surgery.

GI (48 decks)

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