Hernia, rectal

Question 1

haemorrhoids - what is it, rf, syx, ix, mx

Answer 1

Enlarged anal vascular cushions. RF: pregnancy, obesity, inc age and inc intra-abdo pressure, straining

Syx

• Painless bright red bleeding on wiping
• sore/itchy anus
• feeling of lump inside
• Thrombosed: purplish, very tender, swollen lumps, painful, unable to do PR

Ix
- DRE: Mucosal vascular cushions found at 3, 7, 11 oclock of anal canal. This may be below (externa) or below (internal) the dentate line.

Mx

• Avoid straining
• Inc fibre + fluid intake
• Laxatives: bulk-forming - ispaghula (1st line), osmotic or stimulant (2nd line)
• syx relief: topical steriod for few days
• Non surgical Rx: Rubber band ligation
• Surgery if no response to above: artery ligation or haemorrhoidectomy

Thrombosed
- Admission if <72hrs for surgery. Or conservative Rx: Ice packs, laxatives, analgesia

Question 2

Anal fissures -

Answer 2

Can be classified as:

• Acute — if present <6w
• Chronic — if present >6w
• Primary — no cause
• Secondary — underlying cause e.g. constipation, IBD, STI, or colorectal cancer.

Presentation

• Pain with defectation
• +/- bright red rectal bleeding
• Anal spasms

Mx
Primary fissure
- Soften stool: inc fluid + fibre intake, consider laxative
- Pain relief: simple analgesia, warm bath. Consider topical anaesthetic for few days if extreme pain. Consider GTN ointment for 6-8w.

Chronic fissure

• Topical GTN (1st line)
• If fails after 8w -> secondary care referral for sphincterotomy or botox

Question 3

Pilonidal disease - what is it, rf, syx, mx

Answer 3

Develops as a result of hair debris collecting in intergluteal pores, over time this leads to sinus formation.

• Infection of the region may precipitate abscess formation.
• RF: male, 15-40y, white, hirsutism, obesity

Presentation

• asyx = one or more non-tender pits/lumps +/- hair
• acute abscess = painful/tender lump, fluctuant, purulent discharge
• discharging pilonidal sinus = chronic pain, pus or blood, recurrent abscess formation + infection

Mx
- Asyx: reassure, watchful wait, hygiene

• Acute pilonidal abscess: Urgent same day incision + drainage, analgesia, abx if cellulitis
• Discharging pilonidal sinus: refer for surgical excision

Question 4

What is a hiatus hernia?

Answer 4

herniation of part of the stomach above the diaphragm

RF = obesity, prev hiatal surgery, inc intrabdo pressure (chronic cough, multiparty, ascites)

Two types

• sliding (95%): Gastro-oesophageal junction slides up into the chest -> GORD syx
• rolling: stomach bulges thorugh oesophagus hiatus, gastro-oesophageal junction remains intact

Syx

• Heartburn
• Dysphagia
• Regurgitation
• Odynophagia
• CP
• chronic cough

IX

• Barium swallows
• Endoscopy
• Oesophageal manometry

Mx

• Lifestyle: wt loss, elevate head at end of bed, avoid large meals, eat 3-4 hrs before bed, avoid alcohol + acidic, smoking
• Medical: PPI for 4-8w
• Surgery: Nissen’s fundoplication