Perianal Disease Lecture Powerpoint

Question 1

Risk factors for hemorrhoids (2)

Answer 1

• postpartum

- portal hypertension

Question 2

Hemorrhoids symptoms (5)

Answer 2

• pain (external)
• thrombosis
• skin tags
• bleeding (internal)
• prolapse

Question 3

Hemorrhoids treatment options (7)

Answer 3

• bulking agents
• stool softeners
• anal canal suppositories
• creams
• promote hemorrhoid fixation to rectal wall to improve prolapse
• banding, sclerotherapy, electrodessication
• surgery

Question 4

Hemorrhoid therapy complications (5)

Answer 4

• bleeding from banding, especially in those on anticoags
• impotence or urinary retention with sclerotherapy
• pain or blistering from electrocoagulation
• urinary retention in hemorrhoidectomy
• anovaginal fistula in circular stapling

Question 5

What grade of hemorrhoids require surgical approach?

Answer 5

Grade 3 unresponsive to nonsurgical approaches or grade 4 or those with combined internal and external components

Question 6

Surgical therapy options for hemorrhoids (3)

Answer 6

• excisional hemorrhoidectomy
• circular stapling
• transanal hemorrhoidal dearterialization

Question 7

Anal fissure definiton

Answer 7

Tear in anoderm between anal verge and dentate line, most common in posterior midline, often heal within 2-4 weeks, etiology due to tight internal anal sphincter

Question 8

Anal fissure common presentation (3)

Answer 8

• pain during defecation that feels like passing broken glass that relieves an hour or so after passing
• bright red blood
• presence of sentinel pile (chronic ones - see heaped up skin on outside of fissure implying it has been chronic)

Question 9

Anal fissure treatment options (5)

Answer 9

• avoid constipation (bulking agents)
• topical anesthetic agents
• diltiazem paste
• nitroglycerine paste (relaxes smooth muscle in the internal anal sphincter)
• botox injections
• anal dilatation in chronic
• lateral internal sphincterotomy (females need to go lateral opposed to anterior posterior because of vagina compromise)***

Question 10

Anal fistula definition

Answer 10

Tracct with internal opening at level of dentate line and external opening somewhere in skin outside anal verge

Question 11

Anal fistula presentation

Answer 11

Intermittent or persistent drainage from perianal opening, may have been preceding abscess, suspeect if perianal abscess recurs in same space

Question 12

Fistulas surgical therapy general considerations (3)

Answer 12

• will not heal spontaneously
• must identify internal opening
• do not operate on a patient with crohn’s

Question 13

Goodsall’s rule*****

Answer 13

Draw a line transversely across the anus, anything posterior to that will see tracts that are curved into the dentate line, while those anterior will see tracts that are directly straight into the dentate line unless it is 3cm or greater, in which case it will arc to the posterior midline in a curved fashion and then reach the dentate line posteriorally

Question 14

Fistula surgical options (2)

Answer 14

• fistulectomy (pass probe along course of canal, entire canal laid open, tract curetted and granulation tissue removed
• seton placement (thin silicone string placed into the fistula tract allows it to drain and heal)