Peri-anal disorders

Question 1

What are anal cushions?

Answer 1

The anus is lined mainly by discontinuous masses of spongy vascular tissue- the anal cushions that contribute to anal closure

The 3 anal cushions are positioned where 3 major arteries feeding the vascular plexuses enter the canal

They’re attached by smooth muscle and elastic tissue
Prone to displacement and disruption either singly or together

Question 2

What are haemorrhoids/ piles?

same thing

Answer 2

Disrupted and dilated anal cushions

Question 3

What are causes of piles?

Answer 3

Effects of gravity, increased anal tone, and of straining at stool make anal cushions become bulky and loose- protruding to form piles

Constipation with prolonged straining

Minor causes: 
Congestion from pelvic tumour, 
Pregnancy, 
Congestive cardiac failure, 
Portal hypertension

Question 4

What is the dentate line?

Why are haemorrhoids above the line not painful?

Answer 4

Divides the upper two thirds and lower third of the anal canal. Developmentally represents hind-gut, proctodeum junction

There are no sensory fibres above the dentate line

Question 5

Why do haemorrhoids present with PR bleeding?

Answer 5

Vulnerable to trauma via hard stools

Bleed readily from capillaries of underlying lamina propria, bright red blood is lost from the capillaries

Question 6

Pathophysiology of piles?

Answer 6

Vascular cushions protrude through a tight anus
Become more congested and hypertrophy
Protrude again more readily
Protrusions may then strangulate

Question 7

How do haemorrhoids present?

Answer 7

Bright red rectal bleeding:
Coating stools/ on tissue/ dripping into pan after defecation

Mucous discharge and pruritus ani (itchy anus)

Severe anaemia

If weight loss, tenesmus, change in bowel habit consider other pathology

Question 8

Differential diagnosis of haemorrhoids ?

Answer 8

Anal fissure
Abscess
Peri-anal haematoma
Tumour

Question 9

Diagnostic tests and results for haemorrhoids

Answer 9

All rectal bleeding requires:
Abdo exam,
PR exam, (Prolapsing piles are obvious, internal haemorrhoids are not palpable)

Protoscopy to see internal haemorrhoids
Sigmoidoscopy to see pathology higher up

Question 10

Medical treatment for haemorrhoids?

Answer 10

Topical analgesics and stool softener

Increase fluid and fibre intake

Question 11

Non surgical procedures for haemorrhoids?

Answer 11

Ribber band ligation- band produces an ulcer to anchor the mucosa. SEs: infection bleeding pain

Sclerosants: phenol injected into pile above the dentate line. SEs: impotence and prostatitis

Infrared coagulation: coagulates vessels and tethers mucosa to subcutaneous tissue

Question 12

Surgical treatment of haemorrhoids?

Answer 12

Excisional haemorrhoidectomy
Stapled haemorrhoidopexy
Surgical complications- constipation, infection, stricture, bleeding

Question 13

What are sclerosants?

Answer 13

Injectable irritants

Question 14

What is impotence?

Answer 14

Man can’t get an erection or orgasm

Question 15

What is an anal fistulae?

Answer 15

A track communicates between skin and anal canal/ rectum

Blockage of deep intramuscular gland ducts predisposes to formation of abscesses, which discharge to from fistulae

Question 16

Causes of anal fistulae?

Answer 16

Peri-anal sepsis
Abscesses
Crohn's disease
TB
Diverticular disease
Rectal carcinoma

Question 17

Tests for anal fistulae?

Answer 17

MRI

Endo-anal ultrasound scan

Question 18

Treatment

Answer 18

Fistulotomy + exscison

High fistulae that involves continence muscles of anus require a seton suture- tightened over time to maintain continence

Low fistulae are left open to heal naturally (secondary intention)

Question 19

What is an anal fissure?

Answer 19

Painful tear in the squamous lining of the lower anal canal

Often, if chronic, with sentinel pile or mucosal tag at external spectrum

(females > males, 90% are posterior)

Question 20

Aetiology of anal fissures?

Answer 20

Hard faeces
Parturition causes anterior fissures

Rare causes: Syphilis, Herpes, Trauma, Crohn’s, Anal cancer, Psoriasis

Question 21

Anal spasms may constrict the inferior anal artery, what are the effects of this?

Answer 21

Ischaemia, makes healing difficult and perpetuates the problem

Question 22

Treatment for anal fissures?

Answer 22

Lidocaine ointment+ GTN ointment or topical diazepam

Increase dietary fibre and fluids +- stool softener

2nd line= bo tox injection

Surgical option= lateral sphincteotomy

Question 23

How does lidocaine work?

Answer 23

Common local anaesthetic
Uncommonly anti-arrhythmic drug
Enters cells and blocks voltage gated sodium channel
Blocks nerve fibres—> anaesthesia
In heart lidocaine increases refractory period and slows heart rate
SEs: stinging when administered, neurological effects

Question 24

What is a peri- anal abscess?

Answer 24

Anal abscess is a painful condition in which a collection of puss develops near the anus

Usually caused by gut organisms
More common in females

Question 25

Treatment for perianal abscess?

Answer 25

Incise and drain under anaesthetic