Haemarhoids and anal fissure Flashcards
Describe haemorrhoids
Enlarged veins in the lower rectum and anus
Why do haemorrhoids occur?
Veins become swollen due to increased pressure, due to constipation or pregnancy.
How can haemorrhoids be classified?
Internal - above the dentate line. Internal veins which collapse outwards.
External - below dentate line. Perianal veins covered in skin.
What are the different types of epithelium at the dentate line?
Above = columnar epithelium Below = simple squamous
What is the different innervation around the dentate line?
Above = somatic innervation therefore cannot cause pain Below = pudendal nerve and sacral plexus
What vessels supply the haemarrhoidal veins?
Superior rectal arteries
Middle rectal vein
Inferior rectal vein
Where do the internal and external haemarrhoids drain into?
Internal = superior rectal vein into the portal system External = inferior rectal to IVC
How can you examine haemorrhoids?
External are seen on visual examinationDR/anoscopy for internal
Describe the grading system for haemarrhoids
1 = no prolapse, prominent blood vessels 2 = prolapse on bearing down, spontaneous reduction 3 = prolapse on bearing down, need manual reduction 4 = prolapse with inability to be reduced
What is the conservative management for haemorrhoids?
Diet - Increase fibre and fluid - Bulk forming laxative Medical - Simple analgesia - Cream - Stool softeners Surgical - Banding - Injection - HALO - Haemmorhoidectomy
How do haemorrhoids present?
Bright blood in stool
Pain or itch
Mucus discharge
What are the surgical treatments for haemorrhoids?
Banding
Injection
Haemorrhoidectomy
Describe anal fissures
Tear in the squamous lining of the lower anal canal
What causes anal fissure?
Trauma - hard/painful bowel movements
Prior anal surgery
How do anal fissures present?
Pain on defecation
Bleeding
What are the treatments for anal fissures?
- Diet - increase fibres
- Laxatives to prevent constipation
- GTN or diltiazem cream - increase blood flow to area, increasing rate of healing
- Surgery - botox injection or sphincterotomy
Give differences between acute and chronic anal fissures
Acute = red, v painful, unable to perform DRE Chronic = white, less painful, DRE possible
Where do anal fissure normally occur?
12 o’clock position (posteriorly)
6 o’clock in pregnancy
Describe an anal fistula
Chronic abnormal communication between epithelia and anal canal. Caused by an anal abscess
How does an anal fistula develop?
Outlet of the internal glands of the anus become blocked leading to abscess formation. The gland cannot drain.
Describe the track of the fistula
Lined by granulation tissue which connect the anal canal to the skin
Where do the vascular mucosal cushions in the anal canal drain?
Male = vesical venous plexus Female = uterovaginal plexus
What are the main causes of haemmorhoids?
Constipation with prolonged straining
Pregnancy
DDX for haemmorhoids?
Colorectal cancer
Anal fissure
Anal abscess
Tumour
What investigations will you do in someone with haemmorhoids?
DRE
Proctoscope
Sigmoidoscope
Why is the positioning for anal fissures important?
If not in midline, then need to think about SCC or Crohn’s disease
Why do anal fissures occur?
Hard stool and constipation cause a tear which leads to pain on defecation, leading to more constipation and further tearing on passing stool.
Why is diltiazem preferred over GTN cream for anal fissures?
GTN causes headaches
Define a perianal abscess
A collection of pus at the anal margin which causes distortion
Define a ischiorectal abscess
A collection of pus which lies lateral to the anus, is much larger and tracks around the back of the anus.
Describe the pathology behind the development of anal abscesses
Start in the anal gland and then track down to the perineum
What are the complication that can arise with anal abscesses?
Gangrene
Systemic sepsis
In which groups of people are anal abscesses common?
Diabetics
Immunocompromised
Obese
Describe the presentation of someone with a perianal abscess
Common in 20-50 year olds
Males
Gradual onset of severe throbbing pain which makes sitting and defecating difficult
Describe a pilonidal sinus
Sinus containing hairs. Usually as a result of hairs that get pulled into a dimple or pierce the skin therefore leading to infection.
Describe the acute presentation of someone with a pilonidal sinus
Pain and discomfort
Onset over few days
Painful, fluctuant lump
Describe the chronic presentation of someone with a pilonidal sinus
Chronic pain
Discharge
Over two year - pain relapses
Describe the treatment for a pilonidal sinus
Acute - incision adn drainage
Primary intention healing vs secondary intention healing
