Perianal Disease

Question 1

common history in anal fissure?

Answer 1

sharp pain on moving bowels and for a short time after

not long standing pain

Question 2

important aspects of history in perianal disease?

Answer 2

usual pain questions
blood/pus/mucus?
staining in underwear?
ask about continence
obstetric history
anything coming out (eg piles)?
itch?

Question 3

type of pain in haemorrhoids?

Answer 3

dull

throbbing

Question 4

what is the dentate/pectinate line?

Answer 4

line where mucosa changes to anal skin

line where sensation is lost

Question 5

types of haemorrhoids?

Answer 5

external thrombosed

internal

Question 6

grades of haemorrhoids?

Answer 6

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

Question 7

other symptoms associated with bad haemorrhoids?

Answer 7

the piles are wet and mucous producing so might feel that

the piles interrupt the seal so can have problems keeping clean etc

Question 8

management of haemorrhoids?

Answer 8

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

Question 9

describe thrombosed external haemorrhoid?

Answer 9

brusing around rectum
small black dot/scab
pain

Question 10

management of thrombosed external haemorrhoid?

Answer 10

can drain the haematoma under local anaesthetic which gives instant relief

Question 11

how do perinanal abscesses generally present?

Answer 11

features of sepsis half the time
other half its a local problem
severe pain

Question 12

what can perianal abscesses be associated with?

Answer 12

underlying illness
crohns, UC, diabetes, obesity etc
minority have an underlying perianal fistula feeding the abscess which will continue to be a problem

Question 13

principles of treating an abscess?

Answer 13

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

Question 14

classifications of anal fistulae?

Answer 14

extrasphinteric
suprasphincteric
transsphincteric
intersphincteric
submucosal

Question 15

treatments for anal fistulae?

Answer 15

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)

Question 16

how does a fistula form?

Answer 16

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

Question 17

management of a rectal prolapse?

Answer 17

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

Question 18

less common causes of perianal disease?

Answer 18

genital herpes

anal cancer

Question 19

how does a seton stitch work in managing a fistula?

Answer 19

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

Question 20

what might multiple fistulas indicate?

Answer 20

IBD (esp crohns disease)

Question 21

fistulas often co-exist with an abscess, why?

Answer 21

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

Question 22

classical features of a fistula?

Answer 22

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

Question 23

what is a pilonidal abscess?

Answer 23

abscess originating in the hair follicle
always found in natal cleft (between buttocks)
common in younger men

Question 24

management of pilonidal abscess?

Answer 24

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

Question 25

when is banding used to treat haemorrhoids?

Answer 25

only really useful in grades 1 and 2

good for bleeding haemorrhoids

Question 26

when is surgery used for haemorrhoids?

Answer 26

if problematic (painful, leaking, long standing etc)
grades 3 and 4

Question 27

types of haemorrhoid surgery?

Answer 27

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