Haemorrhoids & Anal Fissure

Question 1

What is haemorrhoidal tissue?

Answer 1

A part of the the normal anatomy which contributes to anal continence (along with the internal and external sphincters).

These are mucosal vascular cushions that contain connections between the arteries and veins.

Question 2

What are haemorrhoids?

Answer 2

Haemorrhoids are enlarged anal vascular cushions.

Question 3

What are haemorrhoids often associated with?

Answer 3

• Constipation or straining
• Pregnancy
• Obesity
• Increased age
• Increased intra-abdominal pressure (e.g., weightlifting or chronic coughing)

Question 4

Location of anal cushions?

Answer 4

The location of pathology at the anus is described as a clock face, as though the patient was in the lithotomy position (on their back with their legs raised).

12 o’clock is towards the genitals and 6 o’clock is towards the back.

The anal cushions are usually located at 3, 7 and 11 o’clock.

Question 5

What are the 2 types of haemorrhoids?

Answer 5

1) external –> originate below the dentate line

2) internal –> originate above the dentate line

Question 6

What is the dentate line?

Answer 6

The junction between the superior and inferior anal canal.

Question 7

Haemorrhoids can be graded based on what?

Answer 7

Whether they prolapse from the anus

Question 8

Describe grade I to IV of haemorrhoids

Answer 8

Grade I: do not prolapse out of anal canal

Grade II: prolapse on defecation but reduce spontaneously

Grade III: can be manually reduced

Grade IV: cannot be reduced

Question 9

What is the most common symptom of haemorrhoids?

Answer 9

Painless rectal bleeding

Question 10

Features of haemorrhoids?

Answer 10

1) painless rectal bleeding

2) pruritus

3) pain: usually not significant unless piles are thrombosed

4) soiling may occur with third or forth degree piles

Question 11

Describe rectal bleeding in haemorrhoids

Answer 11

Painless, bright red bleeding, typically on the toilet tissue or seen after opening the bowels.

The blood is not mixed with the stool (this should make you think of an alternative diagnosis).

Question 12

Examination results in haemorrhoids?

Answer 12

1) External (prolapsed) haemorrhoids are visible on inspection as swellings covered in mucosa

2) Internal haemorrhoids may be felt on a PR exam (although this is generally difficult or not possible)

3) They may appear (prolapse) if the patient is asked to “bear down” during inspection

Question 13

What investigation is required for proper visualisation and inspection of haemorrhoids?

Answer 13

Proctoscopy - inserting a hollow tube (proctoscope) into the anal cavity to visualise the mucosa.

Question 14

mx of haemorrhoids?

Answer 14

1) soften stools: increase dietary fibre and fluid intake

2) topical local anaesthetics and steroids may be used to help symptoms

3) outpatient treatments: rubber band ligation

4) surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments

Question 15

What is a key complication of haemorrhoids?

Answer 15

Thrombosed haemorhoid

Question 16

What are thrombosed haemorrhoids?

Answer 16

When blood clots form within the haemorrhoidal veins, leading to swelling, inflammation, and pain.

This can cause significant discomfort and pain for patients.

Question 17

Clinical features of thrombosed haemorrhoids?

Answer 17

Patients often present with a sudden onset of symptoms, frequently following activities that increase intra-abdominal pressure such as heavy lifting, straining during defecation, or prolonged sitting.

1) pain

2) perianal swelling

3) palpable mass

4) bleeding

5) prolapse

6) pruritus ani

Question 18

What is an anal fissure?

Answer 18

A longitudinal tear in the anoderm (the specialized squamous epithelium that lines the distal anal canal).

They are commonly caused by increased anal resting pressure, trauma, and constipation.

Question 19

The aetiology of anal fissures can be broadly classified into primary (idiopathic) and secondary causes.

Give some 1ary causes

Answer 19

The majority of anal fissures are idiopathic in nature, with no clear underlying cause.

However, some factors may contribute to their development:

1) Increased anal resting pressure

2) Trauma e.g. passage of hard stools

3) Constipation & straining

Question 20

Give some causes of 2ary anal fissures

Answer 20

1) IBD

2) Infections e.g. STIs

3) Malignancy e.g. rectal cancer

4) Proctitis

Question 21

Acute vs chronic anal fissure?

Answer 21

Acute: <6 weeks

Chronic: >6 weeks

Question 22

Features of anal fissures?

Answer 22

1) Pain

2) Rectal bleeding

3) Pruritus ani

4) Discharge

5) Constipation

Question 23

Describe pain in anal fissures

Answer 23

Typically described as sharp, severe, and localised to the anus.

Pain is usually most intense during and immediately after bowel movements, often persisting for several minutes to hours.

Question 24

Where are the majority of anal fissures located?

Answer 24

Posterior midline

Question 25

Mx of acute anal fissure? (<6 weeks)

Answer 25

1) dietary advice: high-fibre diet with high fluid intake

2) bulk-forming laxatives are first-line - if not tolerated then lactulose should be tried

3) lubricants such as petroleum jelly may be tried before defecation

4) topical anaesthetics

5) analgesia

Question 26

1st line laxative in anal fissures?

Answer 26

Bulk forming

Question 27

Mx of chronic anal fissure? (>6w)

Answer 27

1) techniques for acute should be continued

2) topical GTN is first-line treatment for a chronic anal fissure

3) if topical GTN is not effective after 8 weeks then secondary care referral should be considered for surgery or botulinum toxin

Question 28

1st line for chronic anal fissure?

Answer 28

topical GTN