Week 7/8 - G - Haemorrhoids (+ perianal haematoma), Rectal prolapse, Anal fissure, Fistula in ano, Pilonidal sinus, Pruritus ani

Question 1

We shall discuss benign disorders of the perianal area in this flashcard set * Haemorrhoids * Rectal prolapse * Anal fissure * Fistula in ano * Pilonidal sinus * Pruritus ani What are haemorrhoids? What is the colloquial name for haemorrhoids?

Answer 1

Haemorrhoids (aka piles) is the dilatation of the anal vascular cushions

Question 2

What are the clinical features of haemorrhoids?

Answer 2

Painless bleeding Fresh, bright red blood, not mixed with stool, usually on the paper Perianal itchiness No change in bowel movement or weight loss

Question 3

What are the classical position of the haemorrhoids? (this relates to the position of the anal vascular cushions) Which artery are the anal vascular cushions branches of?

Answer 3

The classical position of the haemorrhoids corresponds to the braanches of the anal vascular cusjons which are branches of the superior rectal artery (aka superior haemorrhoidal artery) These cushions occur at 3, 7 and 11o’clock with the patient in the lithotomy position

Question 4

What are the different types of anal haemorrhoids?

Answer 4

External originate below the dentate line, prone to thrombosis and may be painful Internal originate above the dentate line, do not generally cause pain Mixed - originate above and below

Question 5

How are the anal haemorrhoides graded?

Answer 5

Haemorrhoids Grade 1 - remain in the rectum Grade 2 - prolapse through the anus on defecation but spontaneously reduce Grade 3 - prolapse through the anus on defecation but require digital reduction Grade 4 - remain persistently prolapsed

Question 6

What are the different causes of haemorrhoids?

Answer 6

Causes * Constipation with straining is a key factor Rectal varices present similarly but are due to portal hypertension

Question 7

What investigations are carried out in the diagnosis of haemorrhoids? What is carried out in patients aged 50 and above?

Answer 7

PR examination (internal haemorrhoids are not palpable) and proctoscopy for initial investigations In all patients aged 50and above - colonoscopy/flexible sigmoidoscopy to exclude proximal pathology

Question 8

The management of haemorrhoids depends on the degree / response to treatment Ranges from conservative management, to non-operative to operative WHat is the conservative management? - usually for internal haemorrhoids that remain in the rectum

Answer 8

Increase fluid and fibre in the diet and avoid straining

Topical local anaesthetics can be give and steroids may be used to help symptoms short period only (annusol is a topical steroid)

Question 9

What is the usually treatment for 2nd/3rd degree haemorrhoids? (or if conservative management has failed)

Answer 9

Rubber band ligation is usually the next step and is generally preferred to sclerosants (sclerosants have a higher recurrence rate) * Rubber band ligation is a procedure in which elastic bands are applied onto an internal hemorrhoid to cut off its blood supply. * Sclerotherapy involves the injection of a sclerosing agent, such as phenol, into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up

Question 10

What are the surgical treatment options for 4th degree hamorrhoids? (or haemorrhodis that are unresponsive to previous treatment?

Answer 10

Surgery is reserved for large symptomatic haemorrhoids which do not respond to previous management - options * Excisional hemorrhoidectomy - greater post-op pain but less hemorrhoid recurrence than both of below * Stapled haemorrhoidectomy (haemorrhoidopexy) * Doppler guided haemorrhoidal artery ligation operation (aka HALO procedure)

Question 11

How do acutely thrombosed external haemorrhoids appear? What are they also known as?

Answer 11

Acutely thrombosed external haemorrhoid is also known as a perianal haematoma examination reveals a purplish, oedematous, tender subcutaneous perianal mass

Question 12

What is the management of an acutely thrombosed haemorrhoid? (usually external ones)

Answer 12

If patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days

Question 13

Rectal prolapse What is a rectal prolapse? What are the different types of rectal prolapse?

Answer 13

Partial rectal prolapse (type 1) - where only the rectal mucosa is involved in prolapsing Complete rectal prolapse (type 2) - involved the rectal mucosa and muscle - more common

Question 14

How does a rectal prolapse present? What is it associated with?

Answer 14

Presents with a * Protruding mass from anus especially during defecation * May reduce spontaneously * Bleeding and passing mucus per rectum is common * Poor anal tone Associated with multiparous women - causes a lax anal sphincter

Question 15

How is rectal prolapse diagnosed?

Answer 15

PR exam is necesary and proctoscopy usually Often can easily be seen just by looking

Question 16

What is the management options of an incomplete rectal prolapse?

Answer 16

Dietary advice - increasing fibre and fluid intake to soften stools, topical analgesics and a stool softeneer also (reduce constipation)

Question 17

Management of a complete rectal prolapse is usually surgery (if too frail for surgery, incomplete prolapse management is advised) What are the different surgical procedures for treating a complete rectal prolapse?

Answer 17

Perineal approach * Delormes procedure - which excises mucosa and sutures the mucosal boundaries Abbdominal rectopexy - laproscopic or open - the rectum is fixed to the sacrum (rectopexy) +/- mesh inserted

Question 18

ANAL FISSURE What is an anal fissure? (fissure in ano) Where in the anus is it usually located?

Answer 18

An anal fissure is a tear in the anal margin usually in the midline posteriorly (90%) but occasionally may be anterior

Question 19

What is the usual cause of an anal fissure? What are other causes?

Answer 19

Most anal fissures are due to hard faeces (constipated stool) causing a tear in the anal squamous lining Rare causes (multiple / lateral fissures) include Crohn’s disease, anal cancers

Question 20

How does an anal fissure present?

Answer 20

Presents with painful rectal bleeding - especially following an episode of constipation - blood on tissue, not in stool Acute onset of severe anal pain usually following episode of constipation “Glass passing through the back passage” Pain lasts for up to ½ h after defecation Bright rectal bleeding

Question 21

What is the conservative advice given for the management of anal fissures? What is the 1st line? How do these drugs work?

Answer 21

COnservative advice is to increase dietary fibre / fluids and potentially take a bowel softener 1st line Lidocaine ointment + GTN ointment (Nitrate) (0.2-0.4%) or topical diltiazem (CCB) (2%) * Relaxes the sphincter muscle preventing spasm and also dilates the arteries allowing healing of the tear

Question 22

What is the 2nd and 3rd line management of an anal fissure?

Answer 22

2nd line – Can try Botulimin toxin again if ointment fails (botox relaxes the sphincter) 3rd line – Surgical sphincterotomy if fissure persists (lateral internal sphincterotomy)

Question 23

Anal fistula What is a fistula? What is thought to be the pathogenesis of an anal fistula?

Answer 23

A fistula is an abnormal communication between two epithelial surfaces An anal fistula is thought to occur due to -> A blockage of a deep intramuscular gland duct predisposes to the formation of an abscess Delay or indequate treatment of the anal abscess leads to discharge to form the fistula

Question 24

What are thought to be causes of the anal abscess / fistula?

Answer 24

Caused by gut organisms But can be associated with Crohn’s, TB or carcinoma

Question 25

How does an anal fistula present?

Answer 25

Symptoms of an anal fistula can include: skin irritation around the anus a constant, throbbing pain that may be worse when you sit down, move around, poo or cough smelly discharge from near your anus passing pus or blood when you poo swelling and redness around your anus and a high temperature (fever) if you also have an abscess The end of the fistula might be visible as a hole in the skin near your anus

Question 26

How is an anal abscess treated?

Answer 26

Anal abscesses are rarely treated with a simple course of antibiotics. In almost all cases surgery will need to take place to remove the abscess. Usually incise and drain under general anaesthetic followed by antibiotics

Question 27

How is an anal fistula investigated?

Answer 27

Digital rectal examination - if possible Examination under anaesthesia (EUA) of anorectum * Proctoscopy / Flexible sigmoidoscopy * MRI

Question 28

Management of an anal fistula can be difficult It depends on whether the fistula is Low - not involving anal sphincters High - involving anal sphincters What is the management for both?

Answer 28

Low (fistulotomy)- laying it open- sphincter is cut open, packed on a daily basis and left to heal by secondary intention High (staged fistulotomy) - Seton suture is placed in the fistula & left for several weeks to help it heal Seton suture is tightened over time to maintain continence and help heal the fistula

Question 29

A novel treatment known as a LIFT (ligation of the intersphincteric fistula tract) procedure is currently being adopted as a treatment to anal fissures What is carried out here?

Answer 29

The ligation of the intersphincteric fistula tract (LIFT) procedure is a treatment for fistulas that pass through the anal sphincter muscles, where a fistulotomy would be too risky. During the treatment, a cut is made in the skin above the fistula and the sphincter muscles are moved apart. The fistula is then sealed at both ends and cut open so it lies flat.

Question 30

Pilonidal sinus What is the pathogenesis of a pilonidal sinus?

Answer 30

Ingrowing of natal hair cleft follicles -> * Excites a foreign body reaction creating a chronic sinus tract to develop -> * Can cause secondary tracts to open laterally +/- foul smelling abscess with foul-smelling discharge

Question 31

What are the risk factors for pilonidal sinus development?

Answer 31

Risk factors include * Male * 16 to 40 * Obese * Barbers can get these between their fingers Tends to present with chronic dishcarge (may be foul smelling), pain and also a visible hole in the skin

Question 32

Pilonidal sinus is a clinical diagnosis What are the treatment options?

Answer 32

Avoid straining and high fibre diet, potentially offer hair removal advice Watch and wait if no signs of infections Treatment of infected sinus options - Excision and leave open for secondary healing - Excision of sinus and close for primary healing - Endoscopic ablation– less invasive than surgery and quicker recovery time than surgical excision

Question 33

Pruritus ani What is pruritus ani? What are often the causes?

Answer 33

Pruritus ani is an itch that occurs around the anus - usually if moist or soiled It is extremely common Associated with * Fissures * Haemorrhoids * lichen sclerosus * Anxiety * Perfumed goods

Question 34

What is the treatment of pruritus ani?

Answer 34

Treatment is largely supportive and patients should avoid using perfumed products around the area. * Soothing ointment if perianal skin is excoriated * Topical corticosteroid if perianal inflammation eg eumovate (clobetasone butryrate) or betnovate (bethametasone valerate)