Hernias and anal disease

Question 1

What are hemorrhoids?

Answer 1

They are actually normal vascular structures that help with the passage of stool. They arise from atriovenous CT

Question 2

Peak incidence of hemorrhoids?

Answer 2

45-65yo and in pregnancy

Question 3

Three types of hemorrhoids & what defines them

Answer 3

External, internal and mixed. Named according to whether they’re distal or proximal to the dentate line

Question 4

Which type of hemorrhoid gets a classification system

Answer 4

Internal!

Question 5

Grade I hemorrhoids

Answer 5

Visualized on anoscopy only. Do not proplapse

Question 6

Grade II hemorrhoids

Answer 6

Proplapse out of anal canal w/ BM or straining. Reduces spontaneously

Question 7

Grade III hemorrhoids

Answer 7

Prolapses out of anal canal w/ BM or straining and REQUIRES MANUAL REDUCTINO

Question 8

Grade IV hemorrhoids

Answer 8

IRREDUCIBLE. WILL STRANGULATE

Question 9

Innveration and hemorrhoids

Answer 9

Internal hem are viscerally innervated, so they aren’t painful. Painless bleeding. If they strangulate and get thrombosed then they’re painful

External hem are somatically innvervated and can be incredibly painful

Question 10

RF for hem

Answer 10

Adv age
Diarrhea
Pregnancy
Pelvis tumor
Prolonged sitting
Straining
Chronic constipation
anticoag tx

Question 11

Clnical sx of a hemorrhoid

Answer 11

40% are asymp!

PAINLESS BLEEDING W/ BM
BRBPR
incontinence
fullness sensation
itchy bumhole
thrombosed? PAIN

Question 12

Painful bleeding w/ BM and it’s not a thrombosed hemorrhoid?

Answer 12

That’s not a hemorhoid. Ask about fever/NS/weight loss because you should be worried about CRC

Question 13

Diagnostic WU for a hemorrhoid

Answer 13

DRE, PE, Anoscopy

Question 14

What do internal hemorrhoid bundles look like on anoscopy?

Answer 14

These are our asymptomatic guys. They’re these bulging, purple blue veins that aren’t tender.

Question 15

What do prolapsed internal hemorrhoids look like on anoscopy?

Answer 15

These dark pink, glistening guys. Sometimes tender

Question 16

What do thrombosed external hemorrhoids look like on anoscopy?

Answer 16

Well first of all, no anoscopy if they’re external. You can see them. They’re acutely tender, purple blue. Sometimes see a clot

Question 17

Tx for G1 hemorrhoid

Answer 17

Painless bleeding, no prolapse. First line symptomatic Rx management, second line RBL

Question 18

Tx for G2 hemorrhoid

Answer 18

Painless bleeding, spontaneously reducible proplapse. Might have some itching. First line sx rx, then RBL

Question 19

Tx for G3 hemorrhoid

Answer 19

Painless bleeding, itching, swelling, soilate. Needs manual reduction. Sxrx and RBL

Question 20

Tx for G4 hem

Answer 20

PAIN. Bleeding. Swelling. ulcerating. Needs surgical excision

Question 21

Nonthrombosed external hem?

Answer 21

Rxtx. RBL

Question 22

Thrombosed external hem management?

Answer 22

Depends on how long its been since the thrombosis happened.

<72 hours? Excision and clot evac.
>72 hours? Body has already started taking care of it. Give support

Question 23

External thrombosed hem recurrence

Answer 23

Wicked common after clot evac. GFL bud

Question 24

3 types of internal hem surgery

Answer 24

1) RBL. Rad for everything Grade I-3, bleeding guys
2) Sclerotherapy. Can be used in grade 1-2 bleeders
3) Hemorrhoidectomy. Grade IV strangulation

Question 25

Common cause of anal pain @ rest that's exacerbated by BM + anal bleeding

Answer 25

Anal fissure!

Question 26

What about anal fissures presentation makes us think it's not cancer

Answer 26

Pain at rest that's exacerbated by BM. Also this is a ton of BRBPR and you can just see the fissure

Question 27

3 kinds of anal fissure

Answer 27

``` Posterior midline (Most common!) Anterior midline (more common in childbirth, ~25% of women) Kissing fissures (exactly what you think it is) ```