Week 2: Minor illness 3/3

Question 1

Haemorrhoids

Answer 1

Haemorrhoids (also known as piles) are abnormally swollen vascular mucosal cushions in the anal canal.

• In the anus, there are three vascular mucosal cushions which help maintain anal continence. These are typically described as being present at the left lateral, right posterior, and right anterior positions (that is, at 3, 7, and 11 o’clock), but there is considerable individual variation.
• When these mucosal cushions become enlarged and symptomatic, they are called haemorrhoids.

Question 2

classification of hameorrhoids

Answer 2

Haemorrhoids are classed as external or internal, depending on their origin in relation to the dentate line.

• Above dentate line
  
  • Visceral pain receptors
  • Columnar epithelium
• Below the dentate line
  
  • Somatic pain receptors
  • Stratified squamous epithelia

The dentate line is situated 2 cm from the anal verge and marks the transition between the upper and lower anal canal.

Question 3

external haemorrhoids

Answer 3

originate below the dentate line and are covered by modified squamous epithelium (anoderm), which is richly innervated with pain fibres. External haemorrhoids can therefore be itchy and painful.

Question 4

internal haemorrhoids

Answer 4

arise above the dentate line and are covered by columnar epithelium, which have no pain fibres. Internal haemorrhoids are therefore not sensitive to touch, temperature, or pain (unless they become strangulated).

Question 5

Risk factors for haemorrhoids

Answer 5

straining during bowel, sitting for long periods on the loo, chronic diarrhoea or constipation, obesity, pregnancy, heavy lifting, anal

Question 6

Presentation of haemorrhoids

Answer 6

• Bright red blood after you poo
• Itchy anus
• Tenesmus
• Lump around anus
• Pain around anus

Question 7

management of haemorrhoids

Answer 7

• Ensure stools are soft and easy to pass fibre and laxatives
• Anal hygiene – perianal cleansing
• Simple analgesia such as paracetamol

Question 8

secondary care of haemorrhoids

Answer 8

• Rubber band ligation

Question 9

grading of intenral haemorrhoids

Answer 9

• Internal haemorrhoids are further graded by degree of prolapse (although these classifications do not always reflect the severity of the symptoms):
  
  • First degree (Grade 1) — haemorrhoids project into the lumen of the anal canal but do not prolapse.
  • Second degree (Grade 2) — haemorrhoids protrude beyond the anal canal on straining but spontaneously reduce when straining is stopped.
  • Third degree (Grade 3) — haemorrhoids protrude outside the anal canal and reduce fully on manual pressure.
  • Fourth degree (Grade 4) — haemorrhoids protrude outside the anal canal and cannot be reduced.
• People can have internal and external haemorrhoids at the same time.

Question 10

Anal fissures

Answer 10

An anal fissure is a tear or ulcer in the lining of the anal canal which causes pain on defecation.

• Anal fissures most often occur in the posterior midline of the anal canal.

Question 11

classification of anal fissure

Answer 11

Classification

• Acute — if present for less than 6 weeks.
• Chronic — if present for 6 weeks or longer.
• Primary — if there is no clear underlying cause.
• Secondary — if there is a clear underlying cause.

Question 12

treatment of anal fissure

Answer 12

• Hydration, dietary fibre, analgesia
• Warm bath
• Medication to relax the internal anal sphincter e.g. GTN

Question 13

causes/RF for anal fissure

Answer 13

• Primary anal fissures do not have a clear underlying cause
  
  • High internal and sphincter tone
  • Reduced blood flow to anal mucosa
• Secondary anal fissures
  
  • Constipation- passage of hard stool tears anal mucosa
  • Conditions which can cause ulceration of the anal mucosa such as
    
    • Inflammatory bowel disease
    • STI e.g. HIV, syphilis and herpes simplex
    • Colorectal cancer
    • Bacterial, fungal or viral skin infection
  • Anal trauma e.g. surgery or sex
  • Pregnancy and childbirth due to pressure on the perineum

Question 14

presentation of anal fissure

Answer 14

• Anal pain when passing stool
  
  • Very serve and sharp, deep burning pain that persists for several hours
• Bleeding may occur with defection
• Tearing sensation

Question 15

management of scabies

Answer 15

1. Treating the affected person and all household members, close contacts, and sexual contacts with a topical insecticide (e.g. permethrin 5% cream or malathion 0.5% liquid), even in the absence of symptoms.
2. Giving detailed advice on how the insecticide should be applied.

Question 16

management of headlice

Answer 16

• Use of mechanical methods, ie wet combing.
• Use of physical insecticides, which act by coating the lice and blocking their oxygen supply. Available products include dimeticone 4% lotion (Hedrin®), dimeticone 92% spray (NYDA®), and isopropyl myristate and cyclomethicone solution (Full Marks Solution®).
• Use of chemical or traditional insecticides, which act by exerting a neurotoxic action and poisoning the lice. In the UK, the only current one which is recommended is malathion 0.5% aqueous liquid (Derbac-M®).