Case 14 - Anal fissures, haemorrhoids, IBD, perianal abcess, fistula Flashcards
what are haemorrhoids
enlarged anal vascular cushions
why do haemorrhoids occur in pregnancy
most likely due to constipation, pressure from the baby in the pelvis and the effects of hormones that relax the connective tissue
what are anal cushions
specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular.
what are anal cushions supported by
smooth muscle and connective tissue.
what do anal cushions help to do
control anal continence, along with the internal and external sphincters
what is the blood supply to anal cushions from
rectal arteries
where are anal cushions usually located
3, 7, and 11 oclock
what is a first degree haemorrhoid
no prolapse
what is a fourth degree haemorrhoid
prolapsed permanently
what are haemorrhoids often associated with
constipation and straining
what is the common presentation of haemorrhoids
painless, bright red bleeding, typically on the toilet papaer or seen after opening the bowels
in haemorrhoids, is the blood mixed with stool
the blood is not mixed with the stool, and if this is seen, it should make you think of an alternative diagnosis
what are the other symptoms of haemorrhoids
sore/itchy anus
feeling a lump around or inside the anus
what is visible on DRE for haemorrhoids
External (prolapsed) haemorrhoids are visible on inspection as swellings covered in mucosa
Internal haemorrhoids may be felt on a PR exam (although this is generally difficult or not possible)
They may appear (prolapse) if the patient is asked to “bear down” during inspection
what is required for proper visualisation and inspection
Proctoscopy is required for proper visualisation and inspection. This involves inserting a hollow tube (proctoscope) into the anal cavity to visualise the mucosa
what is the differential management for patients presenting with symptoms such as rectal bleeding
Anal fissures
Diverticulosis
Inflammatory bowel disease
Colorectal cancer
what topical treatments are given for symptomatic relief and to help reduce swelling
Anusol (contains chemicals to shrink the haemorrhoids – “astringents”)
Anusol HC (also contains hydrocortisone – only used short term)
Germoloids cream (contains lidocaine – a local anaesthetic)
Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term only)
what does prevention and treatment of constipation involve
Increasing the amount of fibre in the diet
Maintaining a good fluid intake
Using laxatives where required
Consciously avoiding straining when opening their bowels
what are the non-surgical treatments for haemorrhoids
Rubber band ligation (fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply)
Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy)
Infra-red coagulation (infra-red light is applied to damage the blood supply)
Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)
what are the three surgical options for haemorrhoids
Haemorrhoidal artery ligation involves using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply.
Haemorrhoidectomy involves excising the haemorrhoid. Removing the anal cushions may result in faecal incontinence.
Stapled haemorrhoidectomy involves using a special device that excises a ring of haemorrhoid tissue at the same time as adding a circle of staples in the anal canal. The staples remain in place long-term.
what are thrombosed haemorrhoids caused by
strangulation at the base of the haemorrhoid, resulting in thrombosis in the haemorrhoid
how do thrombosed haemorrhoids appear
purplish, very tender, swollen lumps around the anus
how are thrombosed haemorrhoids treated
They will resolve with time, although this can take several weeks.
The NICE Clinical Knowledge Summaries (2016) suggests considering admission if the patient present within 72 hours with extremely painful thrombosed haemorrhoids. They may benefit from surgical management.
what is an anal fissure
a tear in the skin that lines the anus below the level of the dentate line
when will anal fissures be painful
on defecation
what diseases are anal fissures associated with
Crohn’s and UC
where do anal fissures usually occur
in the midline posteriorly
what is common to find next to the lesion and what is it sometimes called
An oedemomatous skin tag is common next to the lesion. This is sometimes called a sentinel pile.
why is examination of a fissure often difficult
due to pain and sphincter spasm
what is the treatment of anal fissures
usually an anaesthetic cream and a stool softner
what is given to aid relaxation of the internal sphincter
nitric oxide (GTN cream)
what reduces anal sphincter tone, which in turn increases blood flow and promotes healing
2% diltiazem cream
