Perianal disorders (haemorrhoids, abscess, fistulae, fissures) Flashcards
What are haemorrhoids/piles?
Disrupted and dilated anal cushions (masses of spongy VASCULAR tissue due to swollen veins around the anus
What are the 2 types of piles?
- Internal (Grade 1-4)
- External
What is the difference between internal and external piles?
- Internal haemorrhoids:
Origin above the dentate line (internal rectal plexus) - External haemorrhoids:
Origin below the dentate line (internal rectal plexus)
Give 4 main causes of piles.
- Constipation with prolonged straining is a key factor
- Diarrhoea
- Effects of gravity due to posture
- Congestion from a pelvic tumour, pregnancy, portal hypertension
- Anal intercourse
What are the anal cushions?
- Definition
- Function
- Blood supply
The anal cushions are specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular.
They are supported by smooth muscle and connective tissue. They help to control anal continence, along with the internal and external sphincters.
The blood supply is from the rectal arteries.
Terminology used to describe the location of pathology at the anus.
The location of pathology at the anus is described as a clock face, as though the patient was in the lithotomy position (on their back with their legs raised).
12 o’clock is towards the genitals and 6 o’clock is towards the back.
The anal cushions are usually located at 3, 7 and 11 o’clock.
Classification of haemorrhoids.
The classification of haemorrhoids depends on their size and whether they prolapse from the anus:
1st degree: no prolapse
2nd degree: prolapse when straining and return on relaxing
3rd degree: prolapse when straining, do not return on relaxing, but can be pushed back
4th degree: prolapsed permanently
Give 3 signs + symptoms for haemorrhoids.
- Painless Bright red bleeding (on wiping, not mixed in stool)
- Pruritus ani (itching) and mucus discharge
- Constipation
- Straining
- Lump around or inside the anus
Why can external haemorrhoids be extremely painful?
Extremely painful since there is sensory nerve supply below the dentate line
Investigations for haemorrhoids.
- External examination
= able to see external haemorrhoids
= is difficult to feel for internal haemorrhoids - Digital rectal exam (DRE)
- Proctoscopy (rectal scope)
= able to see internal haemorrhoids
Management of haemorrhoids.
1, Conservative management
2. Prevention of constipation
3. Non-surgical methods
4. Surgery
What is the conservative management for haemorrhoids?
Topical treatments can be given for symptomatic relief and to help reduce swelling.
Treatment of 1st degree haemorrhoids.
- Increase fluid and fibre
- Topical analgesic and stool softener (laxatives)
Treatment of 1st & 2nd degree haemorrhoids.
Non-surgical methods:
- Rubber band ligation:
- Cheap, produces an ulcer to anchor the mucosa (side effects are
bleeding, infection and pain) - Infra-red coagulation:
- Locally coagulates vessels and tethers mucosa to subcutaneous
tissue - Injection sclerotherapy
- Injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy - Bipolar diathermy
- Electrical current applied directly to the haemorrhoid to destroy it
Treatment of 3rd & 4th degree haemorrhoids.
Surgery:
- Excisional haemorrhoidectomy
- Excising the haemorrhoid
- Removing the anal cushions may result in faecal incontinence. - Stapled haemorrhoidectomy
- Using a special device that excises a ring of haemorrhoid tissue at the same time as adding a circle of staples in the anal canal
- The staples remain in place long-term - Haemorrhoidal artery ligation
- Using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply.
