Haemorrhoids & Anal Fissure Flashcards
What is haemorrhoidal tissue?
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.
What are haemorrhoids?
Haemorrhoids are enlarged anal vascular cushions.
What are haemorrhoids often associated with?
- Constipation or straining
- Pregnancy
- Obesity
- Increased age
- Increased intra-abdominal pressure (e.g., weightlifting or chronic coughing)
Location of anal cushions?
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.
What are the 2 types of haemorrhoids?
1) external –> originate below the dentate line
2) internal –> originate above the dentate line
What is the dentate line?
The junction between the superior and inferior anal canal.
Haemorrhoids can be graded based on what?
Whether they prolapse from the anus
Describe grade I to IV of haemorrhoids
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
What is the most common symptom of haemorrhoids?
Painless rectal bleeding
Features of haemorrhoids?
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
Describe rectal bleeding in haemorrhoids
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).
Examination results in haemorrhoids?
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
What investigation is required for proper visualisation and inspection of haemorrhoids?
Proctoscopy - inserting a hollow tube (proctoscope) into the anal cavity to visualise the mucosa.
mx of haemorrhoids?
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
What is a key complication of haemorrhoids?
Thrombosed haemorhoid
What are thrombosed haemorrhoids?
When blood clots form within the haemorrhoidal veins, leading to swelling, inflammation, and pain.
This can cause significant discomfort and pain for patients.
Clinical features of thrombosed haemorrhoids?
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
What is an anal fissure?
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.
The aetiology of anal fissures can be broadly classified into primary (idiopathic) and secondary causes.
Give some 1ary causes
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
Give some causes of 2ary anal fissures
1) IBD
2) Infections e.g. STIs
3) Malignancy e.g. rectal cancer
4) Proctitis
Acute vs chronic anal fissure?
Acute: <6 weeks
Chronic: >6 weeks
Features of anal fissures?
1) Pain
2) Rectal bleeding
3) Pruritus ani
4) Discharge
5) Constipation
Describe pain in anal fissures
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.
Where are the majority of anal fissures located?
Posterior midline
Mx of acute anal fissure? (<6 weeks)
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
1st line laxative in anal fissures?
Bulk forming
Mx of chronic anal fissure? (>6w)
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
1st line for chronic anal fissure?
topical GTN
