Perianal Disease

Question 1

width of anal canal

Answer 1

2-3cm in women
3-4cm in men

Question 2

line of anal valves is called

Answer 2

dentate line

Question 3

the internal anal sphincter

Answer 3

expanded distal portion of the circular muscle of the large intestine
smooth muscle

Question 4

external anal sphincter

Answer 4

striated muscle

Question 5

3 spaces of the anus

Answer 5

1. interphincteric space
2. ischioanal fossa
3. supralevator space

Question 6

sischioanal fossa

Answer 6

lateral to external sphincter

Question 7

supralevator space

Answer 7

between levator ani and rectum

Question 8

haemorrhoids symptoms

Answer 8

present with bleeding, itch and swelling
not painful unless complicated

Question 9

complications of haemorrhoids

Answer 9

prolapse - not painful
thromboses haemorrhoid - very painful

Question 10

painful complication of haemorrhoids

Answer 10

thromboses haemorrhoid

Question 11

haemorrhoids are precipitated by

Answer 11

constipation, pregnancy, straining

Question 12

consider underlying causes of haemorrhoids

Answer 12

churns disease, pregnancy, rarely portal hypertension

Question 13

pathogenesis of haemorrhoids

Answer 13

derived from anal cushions
anal cushions consist of mucosa, submucosal fibroelastic connective tissues and smooth muscle (trietz muscle) in an arteriovenous channel
these may be distended by straining with defamation of hard stools when the submucosa fibres fragment and the cushions become engorged with blood

Question 14

external haemorrhoids

Answer 14

below the dentate line
covered by squamous epithelium
severe pain, especially when thromboses

Question 15

internal haemorrhoids

Answer 15

above the dentate line
arteriovenous fistula
covered by transitional cell or columnar epithelium,

Question 16

grades of internal heamorroids

Answer 16

Question 17

when haemorrhoids become painful

Answer 17

external painful lumps
severe pain on sitting and when defecating
tender to touch

Question 18

haemorrhoids management

Answer 18

ensure no concurrent cancer or IBD with colonoscopy
medical management
rubber band ligation
sclerotherapy
haemorrhoidectomy - excision or stapled

Question 19

medical management of haemorrhoids

Answer 19

bulking laxatives, stool softeners, fibre, steroid cream (proctosedyl)

Question 20

rubber band ligation

Answer 20

applied to base, haemorrhoids tissue then necroses and sloughs off and the wound fibroses
painless if above dentate line
for grade 2 haemorrhoids

Question 21

sclerotherapy

Answer 21

injected into base of the haemorrhoid
reduces blood flow and causes fibrosis

Question 22

haemorrhoidectomy

Answer 22

excision of the haemorrhoid tissue at the base. for grade 3-4
post operatively can be severely painful

Question 23

possible complications of haemorrhoidectomy

Answer 23

anal stenosis, incontinence, bleeding, pain

Question 24

anal fissure is caused by

Answer 24

constipation, straining, childbirth

Question 25

patients with anal fissure present with

Answer 25

severe pain that begins when defecating and can persist for up to several hours

Question 26

aetiology of anal fissure

Answer 26

ischaemic ulcer
caused by spasm of internal sphincter
spasm results in decreased blood flow to ulcer
defecation opens canal causing repeated spasm

Question 27

treatment of anal fissure

Answer 27

treatment is to reduce internal sphincter spasm
topical GTN or diltiazem cream
botilium injection relaxes anal sphincter tone and promotes healing

Question 28

surgical treatment of anal fissure

Answer 28

lateral partial sphincterotomy (to level of anal fissure in depth)

Question 29

ano rectal sepsis

Answer 29

acute abscess
spread from acutely infected anal gland
perianal - swelling at anal margin
inter muscular - swelling within lower rectum
supralevator - fixed swelling above anorectal junction
ischiorecatl - swelling of ischiorectal fossa that often spread circumferentially

Question 30

recurrent absces formation is suspicious for

Answer 30

anal fistula

Question 31

treatment for perianal sepsis

Answer 31

drain pus - operation
not role for just antibiotics
follow up to check for non healing wound

Question 32

fistula in ano

Answer 32

abnormal connection between skin and anal canal

Question 33

untreated sepsis may develop into

Answer 33

fistula in ano

Question 34

when might fistula in ano develop

Answer 34

20% of treated perianal sepsis
untreated perianal sepsis

Question 35

anal fistulas can be treated with

Answer 35

eradication of sepsis
seton
fistulotomy
advancement flaps
glue

Question 36

clinical presentation of anal cancer

Answer 36

pain, bleeding, prruritis
a mass is only present in 20% of cases
advanced tumours may cause faecal incontinence or fistula

Question 37

squamous cell carcinoma

Answer 37

found in anal margin up to the dentate line
common anal malignancy treated with chemoradiotherapy - rarely needs local excision
increased incidence amongst homosexual men or with anal HPV

Question 38

other anal cancers

Answer 38

adenocarcinoma
melanoma
basaxoid carcinoma
lymphoma
sarcoma

Question 39

rectal prolapse most commonly occurs in people like

Answer 39

either mucosal or full thickness
most commonly in elderly women, does occur in younger population

Question 40

rectal prolapse presents with

Answer 40

perianal discomfort, defecating blood or mucous
can become swollen and difficult to manually reduce

Question 41

risk factors for rectal prolapse

Answer 41

risk factors: marfans, Euler-danlos, anorexia nervosa, obesity, childbirth

Question 42

management of rectal prolapse

Answer 42

bulking laxatives and fibre intake
surgery
abdominal - to lift rectum out of pelvis
perineal - to excise and suture mucosa back into rectum

Question 43

tenesumus is

Answer 43

feeling of incomplete defecation

Question 44

haematochezia

Answer 44

bright red rectal bleeding