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
