Haemorrhoids And Anorectal Abscess

Question 1

What are haemorrhoids?

Answer 1

Abnormal swelling or enlargement of the anal vascular cushions

Question 2

How are haemorrhoids classified?

Answer 2

According to their size:

1st degree - remain in the rectum
2nd degree - prolapse through the anus on defecation but spontaneously reduce
3rd degree - prolapse through the anus on defection but require digital reduction
4th degree - remain persistently prolapsed

Question 3

What are the risk factors for haemorrhoids?

Answer 3

Excessive straining (chronic constipation) 
Increasing age 
Raised intra-abdominal pressure (pregnancy, ascites, persistent cough)

Question 4

What are the clinical features of haemorrhoids?

Answer 4

Painless bright red rectal bleeding - blood on surface of stool, after defecation or on paper/ covering pan

Pruritus, rectal fullness, soiling

Prolapsed haemorrhoids can thromboses and are very painful - purple/blue, oedematous, tense and tender perianal mass.

Normally examination is normal

Question 5

What are the differential diagnosis for haemorrhoids?

Answer 5

Malignancy 
IBD
Diverticular disease 
Fistula-in-ano 
Perianal abscess 
Fissure-in-ano

Question 6

What investigations may be done for haemorrhoids?

Answer 6

Proctoscopy
If significant bleeding or signs of anaemia would warrant FBC and clotting screen

Colonoscopy especially in complicated haemorrhoids to exclude concurrent anorectal pathology before surgical intervention

Question 7

What is the conservative management for haemorrhoids?

Answer 7

Lifestyle - increase dietary fibre and fluid intake
Laxatives
Topical analgesia - lignocaine gel (avoid oral opioids as can make constipation worse)

Question 8

What are the surgical options for haemorrhoids?

Answer 8

Symptomatic 1st and 2nd degree haemorrhoids - rubber band ligation (RBL)

2nd and 3rd degree - haemorrhoidal artery ligation (HAL)

3rd and 4th degree - haemorrhoidectomy - left open (Milligan Morgan technique or the mucosa closed over (suturing or stapled)

Question 9

What are the complications of surgical management of haemorrhoids?

Answer 9

Pain
Recurrence
Anal stricturing
Faecal incontinence

Question 10

What is an anorectal abscess?

Answer 10

Collection of pus in the anal or rectal region

Question 11

What do 1/3 of patients with anorectal abscess have?

Answer 11

Perianal fistula

Question 12

What is the pathophysiology of anorectal abscess?

Answer 12

Plugging of anal ducts, resulting in fluid stasis, which can cause infection. Common organisms are E.coli, Bacteriodes spp, enterococcus spp

Question 13

What are the categories of anorectal abscess?

Answer 13

Perianal - most common
Ischiorectal
Intersphincteric
Supralevator

Question 14

What are the clinical feature of anorectal abscess?

Answer 14

Severe pain in perianal region - esp sat down

Discharge or bleeding

Severe abscess have systemic features

Examination:

• erythematous, fluctuant and tender
• severe tenderness on PR exam

Question 15

What are the investigations for anorectal abscess?

Answer 15

Routine bloods

If without any rectal pathology then check HBA1c for underlying DM

Additional imaging such a MRI pelvis for atypical presentation, complex perianal fistula or perianal Crohn’s disease.

Question 16

What is the management of anorectal abscess?

Answer 16

Antibiotics + analgesia

EUA rectum and incision and drainage - under GA, allow to heal with secondary intention

Intraoperative proctoscopy to check for presence of any identified fistula-in-ano - may insert seton if identified

Post op antibiotics - lower risk of fistula formation