Disorders of Perianal Area

Question 1

Haemorrhoids

Answer 1

Enlarged vascular cushions in the lower rectum and anal canal

Question 2

Presentation of haemorrhoids

Answer 2

Painless bleeding - bright red blood not mixed with stool usually on toilet paper, perianal itchiness, no change in bowel habit or weight loss or any other associated symptoms

Question 3

Clinical findings of haemorrhoids

Answer 3

• External inspection can be normal
• Maceration of the perianal skin
• Obvious haemorrhoids if 3rd degree piles presents
• Digital rectal exam – normal unless thrombosed

Question 4

Classic position of haemorrhoids

Answer 4

Corresponding to the branches of the superior haemorrhoidal artery occurring at 3, 7 and 11 o’clock position with the patient in the lithotomy position (back with legs in table top position)

Question 5

Investigations for haemorrhoids

Answer 5

Per rectal exam, rigid sigmoidoscopy, proctoscopy, flexible sigmoidoscopy in patients >50

Question 6

Management of haemorrhoids

Answer 6

Sclerosation therapy with 5% phenol in almond oil, rubber band ligation, open haemorrhoidectomy, HALO/THD procedure

Question 7

HALO procedure:

• What is it?
• Under what anaesthesia is it performed?
• Describe the procedure

Answer 7

• Haemorrhoid artery ligation
• General or spinal anaesthesia
• Miniature doppler ultrasound device locates branches of arteries supplying the haemorrhoids. These blood vessels are tied off, and the haemorrhoid shrinks over the subsequent days and weeks.

Question 8

Presentation of rectal prolapse

Answer 8

Protruding mass from anus especially during defecation, may reduce spontaneously, bleeding and mucus PR is common

Question 9

Examination findings of rectal prolapse

Answer 9

Poor anal tone

Question 10

Management of complete rectal prolapse

Answer 10

Often patients are too weak for surgery, Delorme’s procedure, perineal rectopexy, abdominal rectopexy, anterior resection

Question 11

Management of incomplete rectal prolapse in children vs adults

Answer 11

Children - dietary advice and treatment of constipation

Adults - similar to treatment of haemorrhoids

Question 12

Anal fissure

Answer 12

Tear in the anal margin due to passage of a constipated stool

Question 13

Where is the usual position of an anal fissure?

Answer 13

Midline posteriorly, although can occur anteriorly

Question 14

What condition can cause many anal fissures?

Answer 14

Crohn’s disease

Question 15

Presentation of anal fissure

Answer 15

Acute onset of severe anal pain usually following an episode of constipation. Like “glass passing through the back passage”, lasts for up to 1/2 hour after defecation. Bright rectal bleeding

Question 16

Treatment for anal fissure

Answer 16

Dietary advice, stool softener, pharmacological sphyncterectomy for 6/12, lateral sphyncterectomy, botox injection

Question 17

Fistula in ano

Answer 17

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

Question 18

Causes of fistula in ano

Answer 18

Majority arise from delay in treatment or inadequate treatment of anorectal abscess. Also can present from Crohn’s disease, carcinoma or TB

Question 19

Investigations for fistula in ano

Answer 19

Examination under general anaesthetic of anorectum, rigid sigmoidoscopy, proctoscopy, flexible sigmoidoscopy, MRI

Question 20

Management for fistula in ano

Answer 20

2 stage procedure:

• Insertion of seton (draining, cutting)
• LIFT procedure
• Glue/Permacol
• Defunctioning colostomy

Question 21

Complications of fistula in ano

Answer 21

Pain, bleeding, incontinence of flatus/stool, recurrence, further surgery