Haemorrhoids

Question 1

What is the average length of the anal canal?

1 - 1-2cm
2 - 4-5cm
3 - 5-10cm
4 - 5-12cm

Answer 1

2 - 4-5cm
- normally slightly smaller in females

Question 2

Which of the following is not one of the 3 parts of the anal canal?

1 - distal zone
2 - anal-transitional zone
3 - medial zone
4 - upper zone

Answer 2

3 - medial zone

Question 3

In the upper zone of the anal canal that are longitudinal folds that contain the terminal branches of the superior rectal artery and veins, called anal columns (or columns of Morgagni). What is the function of these columns?

1 - blood supply to anal canal
2 - reduce risk of infection
3 - maintenance of fecal continence and defecation

Answer 3

3 - maintenance of fecal continence and defecation

Question 4

Within the anal canal there is an anatomical line that divides the anal canal into upper (two-thirds) and lower (one-third) parts. What is the name of this line?

1 - denate line
2 - linea abla
3 - inguinal line
4 - mcburneys line

Answer 4

1 - denate line

• also referred to as the pectinate line

Question 5

Within the upper part of the anal canal are the anal columns, which are important for continence and defecation. Where are most prominent places these anal columns are located in the upper part of the anal canal?

1 - left lateral
2 - right posterior
3 - right anterior
4 - all of the above

Answer 5

4 - all of the above

• described as 3, 7 and 11 o’clock when patient is lying supine

Question 6

Do we have physiological haemmorrhoids?

Answer 6

• yes
• function as cushion as stool moves form anal canal

Question 7

The anal columns which act as mucosal cushions in the anal canal can become pathological and cause what?

1 - haemmorrhoids
2 - anal fistulas
3 - rectal prolapase
4 - abscess

Answer 7

1 - haemmorrhoids

Question 8

What is the estimated incidence of haemmorrhoids?

1 - 0.13-0.35%
2 - 1.3-3.5%
3 - 13-36%
4 - 26 - 72%

Answer 8

3 - 13-36%

• probably under-diagnosed due to embarrassment
• more common in men, but pregnant women are most at risk

Question 9

Although there are a lot of risk factors for haemmorrhoids, which if the following are the top 4?

1 - constipation and straining
2 - pregnancy
3 - older age
4 - obesity
5 - increased abdominal pressure
6 - gender

Answer 9

1 - constipation and straining
2 - pregnancy
3 - older age
5 - increased abdominal pressure

Question 10

Organise the following into the correct order for the pathogenesis of haemmorrhoids?

1 - venous return is impaired
2 - bulging mucosa is dragged down by hard stool
3 - causes pelvic floor to sag downwards and can cause a small prolapse
4 - straining due to constipation raises intra-abdominal pressure
5 - venous plexus in anal columns engorge

Answer 10

1 - straining due to constipation raises intra-abdominal pressure
2 - venous return is impaired
3 - venous plexus in anal columns engorge
4 - bulging mucosa is dragged down by hard stool
5 - consistent straining causes pelvic floor to sag downwards and can cause a small prolapse

Question 11

The venous component of the haemmorrhoids can become dangerous if what occurs?

1 - strangulation
2 - incarceration
3 - thrombosis occurs
4 - blood loss

Answer 11

3 - thrombosis occurs

• called a thrombosed external venous saccule

Question 12

There are 4 stages of prolapse, I-IV which are classified on the clinical symptoms. What is the key symptoms that determines what stage a haemorrhoid is placed into?

1 - pain
2 - blood in stool
3 - prolapse
4 - age

Answer 12

3 - prolapse

• stage I - do not prolapse
• stage II - prolapse but spontaneously revert
• stage III - prolapse and need replacing
• stage IV - always prolapsed

Question 13

Which stage of haemorrhoid is generally operated on?

• stage I - do not prolapse
• stage II - prolapse but spontaneously revert
• stage III - prolapse and need replacing
• stage IV - always prolapsed

Answer 13

• stage III - prolapse and need replacing
• stage IV - always prolapsed

Question 14

Which of the following is NOT a common presentation of haemorrhoids?

1 - bleeding (small volumes)
2 - prolapse
3 - skin tags
4 - itching/discharge
5 - UTI symptoms

Answer 14

5 - UTI symptoms

• bleeding is normally painless, bright red and found on toilet paper

Question 15

How long does a attack of symptoms caused by haemorrhoids?

1 - days
2 - days to weeks
3 - weeks
4 - months to years

Answer 15

2 - days to weeks

• symptoms are generally brought on by constipation

Question 16

What is the clinical diagnosis of haemorrhoids?

1 - colonoscopy
2 - proctoscopy
3 - sigmoidoscopy
4 - CT

Answer 16

2 - proctoscopy

• able to look into the anal canal and identify internal haemorrhoids
• need to exclude more serious conditions using qFIT and sigmoidoscopy as well

Question 17

What is the conservative management of haemorrhoids?

1 - banding
2 - oily phenol injections
3 - haemorrhoidectomy
4 - reduce constipation and itching symptoms

Answer 17

4 - reduce constipation and itching symptoms

• creams to manage itching
• laxatives/diet for constipation

Question 18

In addition to conservative management of haemorrhoids, there are 2 procedures that can be performed in an outpatient setting. Which of the following 2 are these?

1 - banding
2 - stapled haemorrhoidectomy
3 - oily phenol injection
4 -haemorrhoidectomy

Answer 18

1 - banding
- done above the dentate line
- reduce prolapse and swelling

3 - oily phenol injection

• 50% recurrence in both

Question 19

A haemorrhoidectomy is the surgical removal of haemorrhoids. Although this can be affective for removing haemorrhoids this can cause significant pain. What is the recurrence following this operation?

1 - 0.1-0.15%
2 - 1-1.5%
3 - 10-15%
4 - 20-30%

Answer 19

3 - 10-15%

• severe pain for 6 weeks

Question 20

A stapled haemorrhoidectomy is where the low rectal mucosa is pushed back into the anal canal and stapled. This us less painful than a haemorrhoidectomy, but urgency can be a problem following the surgery. What is the recurrence following this operation?

1 - 0.2-0.3%
2 - 2-3%
3 - 20-30%
4 - 40-60%

Answer 20

3 - 20-30%

Question 21

Sclerotherapy is another option for surgical treating haemorrhoids. What is this approach?

1 - haemorrhoids cut and cauterised
2 - botox injection into anal columns
3 - irritant solution injected into submucosa around anal columns
4 - steroids injected into submucosa

Answer 21

3 - irritant solution injected into submucosa around anal columns

• results in fibrotic reaction of haemorrhoidal vessels and atrophy of of the haemorrhoides
• 2-3 treatments over 4-6 weeks

Question 22

Haemorrhoid artery ligation is a relatively new technique that involves identifying the artery of each haemorrhoid using ultrasound. A stitch is then placed around the artery to cut off the blood supply. What is the recurrence rate of this procedure?

1 - 0.4%
2 - 4%
3 - 40%
4 - 80%

Answer 22

3 - 40%

• normally painless