Perianal Disease

Question 1

What are hemorrhoids

Answer 1

Dilated/ engorged vascular and connective tissue cushions in anal canal

Question 2

Etiology of hemorroids

Answer 2

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

Question 3

Describe the classification internal hemorrhoids

Answer 3

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

Question 4

Differentiate between external and internal hemorrhoids

Answer 4

External appear below dentate line and are PAINFUL

Internal arise ABOVE dentate line and are PAINLESS

Question 5

Clinical features of hemorrhoids

Answer 5

Bright red painless rectal bleed
Prolapse
Mucus discharge
Tenesmus(feeling of incomplete evacuation)
Pruritus
Pain- never with uncomplicated hemorrhoids

Question 6

Investigation of choice in a patient suspected to have hemorrhoids

Answer 6

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

Question 7

Management option for 1st and 2nd degree hemorrhoids

Answer 7

Rubber band ligation - only done for internal hemorrhoids due to pain ass with external.. strangle excess tissue

Sclerotherapy

Question 8

Management of 3rd and 4th degree hemorrhoids

Answer 8

Hemorrhoidectomy

Question 9

Treatment of a prolapsed thromboses internal hemorrhoids(complicated)

Answer 9

ASS therapy
Analgesia
Sitz bath
Stool softener

Question 10

What are anal fissures

Answer 10

Tear in anal canal below dentate line which contains very sensitive squamous epithelium

Question 11

Eitiology of anal fissures

Answer 11

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

Question 12

Define a chronic anal fissure

Answer 12

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

Question 13

Treatment of chronic fissure

Answer 13

Internal anal sphincter must be addressed: reversible chemical sphincterotomy
Surgical sphincterotomy

Question 14

What is an Ano rectal abscess

Answer 14

Bacterial(usually) infection of blocked anal crypt gland at dentate line

Ecoli proteus strep staph etc

Question 15

Classify anorectal abscess

Answer 15

Ischiorectal (below levator muscle)
Intersphincteric
Surpalevator
Perianal

Question 16

Treatment of anorectal abscesses

Answer 16

Incision and drainage and antibiotics

Question 17

Clinical features of anorectal abscess

Answer 17

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

Question 18

Clinical presentation of a fistula in Ano

Answer 18

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)

Question 19

Treatment of a fistula in Ano

Answer 19

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