Perianal Disease Flashcards
What are hemorrhoids
Dilated/ engorged vascular and connective tissue cushions in anal canal
Etiology of hemorroids
Anything that causes increased intraabdominal pressure: chronic constipation, pregnancy, obesity, portal htn, heavy lifting chronic cough, BPH, connective tissues disorders such as Ehler Danlos and marfans
Describe the classification internal hemorrhoids
1st degree: bleed but don’t prolapse
2nd bleed and prolapse and reduces spontaneously
3rd bleed and prolapse but requires manual reduction
4th bleed but irreducible
Differentiate between external and internal hemorrhoids
External appear below dentate line and are PAINFUL
Internal arise ABOVE dentate line and are PAINLESS
Clinical features of hemorrhoids
Bright red painless rectal bleed
Prolapse
Mucus discharge
Tenesmus(feeling of incomplete evacuation)
Pruritus
Pain- never with uncomplicated hemorrhoids
Investigation of choice in a patient suspected to have hemorrhoids
Flexible sigmoidoscopy and sometimes rigid proctoscopy
Rule out serious causes of rectal bleeding using colonoscopy especially if patient over 35 and has family history of colon cancer
Management option for 1st and 2nd degree hemorrhoids
Rubber band ligation - only done for internal hemorrhoids due to pain ass with external.. strangle excess tissue
Sclerotherapy
Management of 3rd and 4th degree hemorrhoids
Hemorrhoidectomy
Treatment of a prolapsed thromboses internal hemorrhoids(complicated)
ASS therapy
Analgesia
Sitz bath
Stool softener
What are anal fissures
Tear in anal canal below dentate line which contains very sensitive squamous epithelium
Eitiology of anal fissures
Forceful dilation of anal canal
Chronicity resulting in internal anal sphincter spasm
Repetitive injury cycle after first year may lead to sphincter spasm which prevents edges of tear from healing and leads to further tearing
Also ischaemia may ensue
Define a chronic anal fissure
Lasts more than 6 weeks
Features of chronicity: triad of fissure >6 weeks, sentinel skin tags/piles(thickened skin and end of fissure), hypertrophied anal papillae
Treatment of chronic fissure
Internal anal sphincter must be addressed: reversible chemical sphincterotomy
Surgical sphincterotomy
What is an Ano rectal abscess
Bacterial(usually) infection of blocked anal crypt gland at dentate line
Ecoli proteus strep staph etc
Classify anorectal abscess
Ischiorectal (below levator muscle)
Intersphincteric
Surpalevator
Perianal
Treatment of anorectal abscesses
Incision and drainage and antibiotics
Clinical features of anorectal abscess
Perianal abscess
Dull perianal discomfort and pruritus
Erythematous, subcutaneous mass near the anus found by manual inspection
Perirectal abscess
Rectal or perirectal drainage (bloody, purulent, or mucoid)
Severe pain, fever, and chills
Pain exacerbation with sitting and defecation
Clinical presentation of a fistula in Ano
Non healing sore inside anus with recurrent abscess formation
Intermittent or constant purulent discharge from perianal opening
Pain
Palpable cord like tract
Presence of ibd or chrons (fistula usually multiple)
Treatment of a fistula in Ano
Fistulotomy (standard approach)
Possible seton placement (enables adequate drainage and fibrosis)
–A seton is a nonabsorbable nylon or silk thread that is left in the fistula tract to keep it open and promote healing. It is left in place for weeks to months.
Possible fibrin glue or fistula plug
-The insertion of a fistula plug made from porcine submucosa provides the scaffold over which the body’s collagen gets deposited and closes the fistula.
Additional administration of antibiotics and immunosuppressants in patients with Crohn’s disease
