Haemarhoids and anal fissure

Question 1

Describe haemorrhoids

Answer 1

Enlarged veins in the lower rectum and anus

Question 2

Why do haemorrhoids occur?

Answer 2

Veins become swollen due to increased pressure, due to constipation or pregnancy.

Question 3

How can haemorrhoids be classified?

Answer 3

Internal - above the dentate line. Internal veins which collapse outwards.
External - below dentate line. Perianal veins covered in skin.

Question 4

What are the different types of epithelium at the dentate line?

Answer 4

Above = columnar epithelium
Below = simple squamous

Question 5

What is the different innervation around the dentate line?

Answer 5

Above = somatic innervation therefore cannot cause pain
Below = pudendal nerve and sacral plexus

Question 6

What vessels supply the haemarrhoidal veins?

Answer 6

Superior rectal arteries
Middle rectal vein
Inferior rectal vein

Question 7

Where do the internal and external haemarrhoids drain into?

Answer 7

Internal = superior rectal vein into the portal system External = inferior rectal to IVC

Question 8

How can you examine haemorrhoids?

Answer 8

External are seen on visual examinationDR/anoscopy for internal

Question 9

Describe the grading system for haemarrhoids

Answer 9

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

Question 10

What is the conservative management for haemorrhoids?

Answer 10

Diet
- Increase fibre and fluid
- Bulk forming laxative
Medical 
- Simple analgesia
- Cream 
- Stool softeners
Surgical
- Banding 
- Injection
- HALO
- Haemmorhoidectomy

Question 11

How do haemorrhoids present?

Answer 11

Bright blood in stool
Pain or itch
Mucus discharge

Question 12

What are the surgical treatments for haemorrhoids?

Answer 12

Banding
Injection
Haemorrhoidectomy

Question 13

Describe anal fissures

Answer 13

Tear in the squamous lining of the lower anal canal

Question 14

What causes anal fissure?

Answer 14

Trauma - hard/painful bowel movements

Prior anal surgery

Question 15

How do anal fissures present?

Answer 15

Pain on defecation

Bleeding

Question 16

What are the treatments for anal fissures?

Answer 16

1. Diet - increase fibres
2. Laxatives to prevent constipation
3. GTN or diltiazem cream - increase blood flow to area, increasing rate of healing
4. Surgery - botox injection or sphincterotomy

Question 17

Give differences between acute and chronic anal fissures

Answer 17

Acute = red, v painful, unable to perform DRE
Chronic = white, less painful, DRE possible

Question 18

Where do anal fissure normally occur?

Answer 18

12 o’clock position (posteriorly)

6 o’clock in pregnancy

Question 19

Describe an anal fistula

Answer 19

Chronic abnormal communication between epithelia and anal canal. Caused by an anal abscess

Question 20

How does an anal fistula develop?

Answer 20

Outlet of the internal glands of the anus become blocked leading to abscess formation. The gland cannot drain.

Question 21

Describe the track of the fistula

Answer 21

Lined by granulation tissue which connect the anal canal to the skin

Question 22

Where do the vascular mucosal cushions in the anal canal drain?

Answer 22

Male = vesical venous plexus
Female = uterovaginal plexus

Question 23

What are the main causes of haemmorhoids?

Answer 23

Constipation with prolonged straining

Pregnancy

Question 24

DDX for haemmorhoids?

Answer 24

Colorectal cancer
Anal fissure
Anal abscess
Tumour

Question 25

What investigations will you do in someone with haemmorhoids?

Answer 25

DRE
Proctoscope
Sigmoidoscope

Question 26

Why is the positioning for anal fissures important?

Answer 26

If not in midline, then need to think about SCC or Crohn’s disease

Question 27

Why do anal fissures occur?

Answer 27

Hard stool and constipation cause a tear which leads to pain on defecation, leading to more constipation and further tearing on passing stool.

Question 28

Why is diltiazem preferred over GTN cream for anal fissures?

Answer 28

GTN causes headaches

Question 29

Define a perianal abscess

Answer 29

A collection of pus at the anal margin which causes distortion

Question 30

Define a ischiorectal abscess

Answer 30

A collection of pus which lies lateral to the anus, is much larger and tracks around the back of the anus.

Question 31

Describe the pathology behind the development of anal abscesses

Answer 31

Start in the anal gland and then track down to the perineum

Question 32

What are the complication that can arise with anal abscesses?

Answer 32

Gangrene

Systemic sepsis

Question 33

In which groups of people are anal abscesses common?

Answer 33

Diabetics
Immunocompromised
Obese

Question 34

Describe the presentation of someone with a perianal abscess

Answer 34

Common in 20-50 year olds
Males
Gradual onset of severe throbbing pain which makes sitting and defecating difficult

Question 35

Describe a pilonidal sinus

Answer 35

Sinus containing hairs. Usually as a result of hairs that get pulled into a dimple or pierce the skin therefore leading to infection.

Question 36

Describe the acute presentation of someone with a pilonidal sinus

Answer 36

Pain and discomfort
Onset over few days
Painful, fluctuant lump

Question 37

Describe the chronic presentation of someone with a pilonidal sinus

Answer 37

Chronic pain
Discharge
Over two year - pain relapses

Question 38

Describe the treatment for a pilonidal sinus

Answer 38

Acute - incision adn drainage

Primary intention healing vs secondary intention healing