Perianal Surgery Flashcards
Haemorrhoids pathophysiology
Disrupted and dilated anal cushions
• Gravity, straining → engorgement and enlargement of
anal cushions
• Hard stool disrupts connective tissue around
cushions.
• Haemorrhoids arise above dentate line - not painful
Presentation of haemorrhoids
• Fresh painless PR bleeding - Bright red - On paper or stool • Pruritis • Lump in perianal area • Severe pain = thrombosis
Haemorrhoid Investigation
- Full abdo exam
- Inspect perianal area: masses, recent bleeding
- DRE: can’t palpate piles unless thrombosed
- Rigid sig to identify higher rectal pathology
- Proctoscopy
- Anaemia - FBC and a coagulation screen
Mx of haemorrhoids
Conservative:
• ↑ fibre and fluid intake
• Stop straining
Medical: • Topical - Anusol: hydrocortisone + lidocaine - Analgesics • Laxatives: lactulose or fybogel
Interventional: • Injection with sclerosant • Banding → thrombosis and separation • Cryotherapy • Infra-red coagulation
Surgical:
Haemorrhoidal artery ligation
Haemorrhoidectomy - Excision of piles + ligation of vascular pedicles
• Discharge with laxatives post-op
Side effects of haemorrhoidectomy
Bleeding, infection and stenosis
Mx of thrombosed piles
- Analgesia
- Ice-packs
- Stool softeners
- Topical lignocaine jelly
- Pain usually resolves in 2-3wks
- Haemorrhoidectomy is not usually necessary
Anal fissure
Tear of squamous epithelial lining in lower anal canal
Causes of anal fissure
• Hard stool
- Assoc. with constipation
• Rarer causes, often → multiple ± lateral fissures
- Crohn’s
- Herpes
- Anal Ca
- Trauma
Presentation of anal fissure
• Intense anal pain especially on defecation
• Fresh rectal bleeding
- On paper
• pruritis
Examination:
• PR often impossible
• Groin LNs suggest complicating factor: e.g. HIV
Management of anal fissure
Conservative:
• Soaks in warm bath
• Toileting advice
• Dietary advice: ↑ fibre and fluids
Medical: • Laxatives: lactulose + fybogel • Topical: - Lignocaine - GTN ointment - Diltiazem cream CCB
• EUA + botulinum toxin injection
Surgical: Lateral partial sphincterotomy
• Pre-op anorectal US and manometry
If recurrent, chronic anal fissure
EUA is done
Complications of sphincterotomy
- Minor faecal/flatus incontinence (= GTN)
- Perianal abscess
Pilonidal Sinus
Ingrown hair causes foreign body reaction → formation of abscess
Anal Carcinoma
Squamous cell carcinoma (80%)
• Spread
- Above dentate line → internal iliac nodes
- Below dentate line → inguinal nodes
Rectal prolapse
Protrusion of rectal tissue through the anal canal
