Perianal Disease Flashcards
common history in anal fissure?
sharp pain on moving bowels and for a short time after
not long standing pain
important aspects of history in perianal disease?
usual pain questions blood/pus/mucus? staining in underwear? ask about continence obstetric history anything coming out (eg piles)? itch?
type of pain in haemorrhoids?
dull
throbbing
what is the dentate/pectinate line?
line where mucosa changes to anal skin
line where sensation is lost
types of haemorrhoids?
external thrombosed
internal
grades of haemorrhoids?
1 = bleeding, always inside cant be seen 2 = bleeding, come out on bowel movements but go back in by themselves 3 = bleeding and need put back in manually 4 = bleeding and cannot be put back in, out all the time
other symptoms associated with bad haemorrhoids?
the piles are wet and mucous producing so might feel that
the piles interrupt the seal so can have problems keeping clean etc
management of haemorrhoids?
analgesia = first (topical or oral non-opiate so no constipation side effects) reassure explain cause bed rest (if acutely thrombosed vessels) ice filled glove when really acute stool softeners
describe thrombosed external haemorrhoid?
brusing around rectum
small black dot/scab
pain
management of thrombosed external haemorrhoid?
can drain the haematoma under local anaesthetic which gives instant relief
how do perinanal abscesses generally present?
features of sepsis half the time
other half its a local problem
severe pain
what can perianal abscesses be associated with?
underlying illness
crohns, UC, diabetes, obesity etc
minority have an underlying perianal fistula feeding the abscess which will continue to be a problem
principles of treating an abscess?
in theatre open and drain the abscess
must pack it and leave it open a while to let it heal and drain or it will reform
classifications of anal fistulae?
extrasphinteric suprasphincteric transsphincteric intersphincteric submucosal
treatments for anal fistulae?
laying open
seton (plastic tube to keep it open at the external opening of fistula so it drains, then granulates into a well organised tract)
permacol paste
permacol plugs (good for short stubby fistulas)
how does a fistula form?
anal mucosal gland becomes infected and instead of bursting into the anal canal, it bursts backwards into the tissue and the infected puss etc and material tracks backwards and continues forming an opening to the external skin
management of a rectal prolapse?
push it back in
instillagel, sugar and swabs to drain the fluid out of it
check there isnt a tumour pushing it our
long term management = surgical excision (delormes) or abdominal procedure
address weak pelvic floor, weight etc
less common causes of perianal disease?
genital herpes
anal cancer
how does a seton stitch work in managing a fistula?
works the same as an earring prevents ear piercing getting infected
stitch goes right through the whole tract and out the other end and so encourages any pus etc to follow the thread and drain out
what might multiple fistulas indicate?
IBD (esp crohns disease)
fistulas often co-exist with an abscess, why?
pus etc from the abscess will drain via path of least resistance ie out through the fatty tissue emerging at the skin around the anal opening
classical features of a fistula?
visible opening
blood and mucus leaking (feeling wet all the time)
pain from fistula opening continuously trying to heal over then bursting open again with pressure
what is a pilonidal abscess?
abscess originating in the hair follicle
always found in natal cleft (between buttocks)
common in younger men
management of pilonidal abscess?
keep area shaved
excise whole area and leave open as a big hole, keep the hole clean and packed and it will fill in with scar tissue over time
when is banding used to treat haemorrhoids?
only really useful in grades 1 and 2
good for bleeding haemorrhoids
when is surgery used for haemorrhoids?
if problematic (painful, leaking, long standing etc) grades 3 and 4
types of haemorrhoid surgery?
haemorrhoidectomy (not the best anymore)
THD (trans-haemorrhoidal de-arterisation) is good as not leaving any raw areas where haemorrhoid chopped off and less problematic recivert etc
