Perianal Disease

Question 1

Outline the pathogenesis of haemorrhoids

Answer 1

• Excessive straining or increase in abdominal pressure (pregnancy, ascites) causes downward stress on the haemorrhoidal cushions
• Tearing of their thin epithelium can lead to bleeding

Question 2

What are the likely history/examination findings in a patient with haemorrhoids?

Answer 2

• 45-65
• Constipation
• Pregnancy or space-occupying lesion
• Rectal bleeding (bright) associated with defecation
• Perianal pain
• Anal pruritus
• Anal mass (3, 7, 11, o’clock)

Question 3

What are the management prinicples for haemorrhoids?

Answer 3

• Lifestyle changes (mild haemorrhoids)
  
  • Increase fibre, reduce constipation
• Surgical intervention
  
  • Rubber-banding (ligation)/sclerotherapy (moderate haemorrhoids)
  • Surgical haemorrhoidectomy (severe/refractory haemorrhoids)

Question 4

What are the likely findings on history and examination for a patient with anal fissures?

Answer 4

• Post-defecation pain and bleeding
• Sentinel pile/skin tag
• Fissure at 12/6 o’clock

Question 5

What are the prinicples of management of anal fissures?

Answer 5

• Decrease straining
• Topical anaesthetics
• Rectogesic - GTN containing
• Surgery - lateral sphincterotomy

Question 6

What are the likely findings on history/examination for anal abscesses/fistulae?

Answer 6

• Dull, throbbing, continuous pain with relief on discharge
• Goodsall’s rule. If external opening is below 3 and 9, the internal opening is at 6. If above 3 and 9, the internal opening should be at the same radiant line (or at 6)

Question 7

What are the management principles for anal abscesses/fistulae?

Answer 7

• Abscess
  
  • Surgical drainage and antibiotics
• Fistula
  
  • Low fistulas - lay open and allow to granulate
  • High fistulas - seton (draining rubber tubing)