wk 8 5 Rectal Disorders

Question 1

questions to ask for bleeding

Answer 1

fresh/dark?
Mixed with stool?
Dripping in the toilet or just on paper?

Question 2

define haemorrhoids

Answer 2

enlarged vascular cushions of the lower rectum and anal canal

Question 3

haemorrhoids presentation

Answer 3

painless bleeding - fresh, bright red, not mixed with stool
perianal itchiness
no change in bowel habit/weight loss

Question 4

expected clinical findings of haemorrhoids

Answer 4

external inspection may be normal
maceration of perianal skin (breakdown of skin due to moisture)
PR exam - normal unless thrombosed

Question 5

which artery is haemorrhoids most likely to occur in

Answer 5

superior haemorrhoidal artery (occuring at 3,7,11 o’clock when patient in position)

Question 6

suitable investigations of haemorrhoids 4

Answer 6

PR exam
rigid sigmoidoscopy
proctoscopy
flexible sigmoidoscopy if >50

Question 7

management of haemorrhoids 3

Answer 7

symptomatic
sclerosation therapy (5% phenol in almond oil) (dissolves vein)
rubber band ligation
open/stapled haemorrhoidectomy
HALO (Haemorrhoidal Artery Ligation Operation)

Question 8

anesthesia for HALO

Answer 8

general/spinal anesthesia

Question 9

outline the HALO procedure

Answer 9

Miniature doppler ultrasound locates branches of arteries supplying the haemorrhoids, these are then ligated causing the haemorrhoid to shrink

Question 10

t/f HALO procedure is pain-free

Answer 10

true

stitch is placed in lower rectum - virtually no sensory nerves

Question 11

what are the two types of rectal prolapse

Answer 11

partial (anterior mucosal prolapse)

complete (full thickness)

Question 12

presentatioin of rectal prolapse

Answer 12

protruding mass from anus - esp during defecation (may reduce spontaneously)
bleeding/mucus common

Question 13

t/f poor anal tone usually noted on examination in a rectal prolapse

Answer 13

true

Question 14

outline the management of complete prolapse

Answer 14

if too frail for surgery - bulking agent and education on manual reduction
delormes procedure
perineal/ abdominal rectopexy
anterior resection

Question 15

management of incompplete prolapse

Answer 15

most likely due to constipation
in children - dietary advice
in adults - same as haemorrhoids

Question 16

define anal fissure

Answer 16

teal in the anal margin due to passage of a constipated stool

Question 17

multiple fissures indicates

Answer 17

crohns

Question 18

anal fissure most likely to occur in the midline anterior t/f

Answer 18

false

can occur but usually in midline posteriorly

Question 19

presentation of anal fissure

Answer 19

acute onset of severe anal pain following episode of constipation (lasting half an hour)
“glass passing through the back passage”
bright rectal bleeding

Question 20

treatment of anal fissures

Answer 20

dietary advice
stool softeners (docusate sodium)
sphyncterotomy - pharmacological (GTN + Diltiazem ointment) or surgery (lateral internal sphyncterotomy)
botox injection

Question 21

define fistula

Answer 21

abnormal communication between two epithelial surfaces (internal opening - 1+ external opening on peri-anal skin)

Question 22

causes of anal fistula 6

Answer 22

most - arise in treatment delay of anorectal abscess 
crohns
TB
carcinoma 
diverticulitis 
surgery complication

Question 23

investigations for anal fistula

Answer 23

PR exam (under anesthesia)
rigid sigmoidoscopy/proctoscopy
flexible if old
MRI

Question 24

management of anal fistula

Answer 24

laying open procedure (fistula cut open and then left to heal, if fistula is at sphincter may cause incontinence)
seton (draining, cutting) if higher up
LIFT procedure
defunctioning colostomy

Question 25

possibe complications of anal fistula

Answer 25

pain
bleeding
flatus/stool incontinence
recurrence