Peri-Anal Disorders Flashcards
We have 2 anal sphincters. For each of the 2 sphincters state if
striated or not
Voluntary or not
Nerve supply
Internal sphincter: Non-striated, Involuntary, supplied by autonomic nerves
External Sphincter: Striated, voluntary, supplied pudendal nerve
The external sphincter is fused with another muscle which is important for maintaining the anorectal angle.
What is the muscle
What is the importance of maintaining the anorectal angle
Puborectalis Muscle
This muscle supports the anorectal angle which is necessary for continence
The anal canal is divided into the
Upper X/3
Lower X/3
What is X?
What epithelial cells are in each?
What is the arterial supply?
What is the lymphatic drainage?
Upper 2/3 columnar epithelium
Supplied by the superior rectal artery (from inf. mesenteric)
Drains to the internal iliac LN
Lower 1/3 squamous epithelium
Supplied by the Inferior rectal artery (from pudendal artery) - Just like pudendal nerve supplies the external sphincter.
Drainage to the Inguinal LN (important for SCC of anal canal)
When a patient is in a lithotomy position, where are the haemorrhoids typically located?
3, 7, 11 o’clock
There are 2 types of haemorrhoids
Which is typically painful
Which typically bleeds
Internal haemorrhoids are typically painless but cause bleeding and prolapse
External haemorrhoids typically thrombose causing pain and itching
Compare and contrast Internal and external haemorrhoids?
An acute presentation of haemorrhoids is going to be internal or external or can it be both?
Internal: From the bleeding
External: From the pain
Both: From the strangulation-yikes
A patient presents with sudden onset excrutiating pain especially when they sit down. You perform a DRE, it is still very painful and not really made worse by performing the DRE. On inspection, it does look like haemorrhoids (piles). What is the most likely diagnosis?
How is it managed?
Thrombosed External haemorrhoids
ManagementL Surgical evaluation of the haemorrhoid with excision of the skin overlying the thrombosed haemorrhoid. This provides immediate relief to the patient and GG.
There are 4 degrees of haemorrhoids. Go through them
When asked about bleeding PA, what should you ask?
Bowel habits
Blood: when wiping or in bowl? did it fill the bowl/water red? Fresh vs not dark/coffeground etc…
Symptoms of anaemia
What are you looking for on a DRE in haemorroids
Location: 3,7,11
Prolapse, reducibility
Skin tags
If you perform a DRE on a patient suspected of haemorrhoids but its too painful to proceed, the most likely diagnosis is? Give another
Anal fissure
Intersphincteric abscess
Thats 2 ddx now for you
How would you investigate haemorroids? Like any rectal bleed. So you did the abdominal examination. what now?
DRE in lithotomy postition looking for location, prolapse, reducibility etc..
Proctoscopy -> Sigmoidoscopy to rule out colorectal Ca or diverticulitis (thats 2 more ddx)
What is a Sitz bath and how often should a patient do this?
Up to 3x per day
Shallow warm water bath with a pump to squeeze and pump water up in there
What is the conservative/supportive management of Haemorrhoids
AKA what is given/told to every patient with haemorrhoids
1) Only evacuate when natural desire to do so arises and minimal straining and lingering on toilet
2) High fibre diet, increased physical activity, weight loss
3) Stop smoking, change ace inhibitors
+/- stool softeners/bulking agents
+/- Sitz baths 3x/day in warm water
Complications of haemorroids
