Ano-rectal Disease

Question 1

what are haemorrhoids

Answer 1

enlarged vascular cushions in the lower rectum and anal canal

Question 2

what does the dentate lie separate in haemorrhoids

Answer 2

internal and external haemorrhoid (above and below)

Question 3

describe external haemorrhoids

Answer 3

lie under perianal skin, inside and outside the anal verge, covered by squamous epithelium

Question 4

what are the stages of internal haemrrohagin

Answer 4

how likely they are to prolapse:
1- wont
2-prolapse on straining 
3-reduced manually
4-permanent

Question 5

what is the possible extra symptom of external haemorrhoids

Answer 5

itch

Question 6

how do haemorrhoids present

Answer 6

painless bleeding, fresh, bright blood not mixed with stool, usually on the paper,
perianal itchiness,

no change in bowel habit, weight loss or other associated symptoms

Question 7

what is found on clinical exam for haemorrhoids

Answer 7

external can be normal,
maceration (softening and breakdown on skin due to prolonged exposure to moisture),
PR exam normal unless thrombosed (blood clot inside haemorrhage)

Question 8

what does the classical position of haemorrhoids correspond to

Answer 8

the branches of the superior haemorrhoidal artery (3, 7, and 11 o’clock in the lithotomy position)

Question 9

what investigations should be done

Answer 9

PR exam, rigid sigmoidoscopy (flexible in patients over 50), proctoscopy (rectal endoscopy)

Question 10

when do haemorrhoids cause pain

Answer 10

when they become strangulated or thrombosed (which is extremely painful)

Question 11

how are haemorrhoids managed

Answer 11

symptoms treated,
sclerosation therapy (injections with 5% phenol in almond oil to shrink and harden internal), rubber band ligation, open haemorrhoidectomy, stapled haemorrhoidectomy, HALO/THD procedure

Question 12

what is the HALO/THD procedure

Answer 12

haemorrhoidal artery ligation- done under general or spinal ligation

Miniature Doppler ultrasound device locates branches of arteries supplying the haemorrhoids. These blood vessels are tied off, and the haemorrhoid shrinks over the subsequent days and weeks.

Because the stitch is placed in the lower rectum where there are virtually no sensory nerves the procedure is pain-free.

Question 13

what is a partial rectal prolapse

Answer 13

anterior mucosal prolapse

Question 14

what is a full rectal prolapse

Answer 14

protusion of entire wall of rectum

Question 15

how does a rectal prolapse present

Answer 15

protruding mass from anus especially during defecation,
may reduce spontaneously,
bleeding and passing mucous PR is common,
pain, incontinence, constopation

Pr shows
poor anal tone
ulcer

Question 16

how are complete rectal prolapses managed

Answer 16

many too frail for surgery- bluking agent and education on manual prolapse

surgery;

• delormes procedure
• perianal rectopexy
• abdominal rectopexy
• anterior resection

Question 17

how can you tell a haemorrhoid from a prolapse

Answer 17

prolapse has symmetrical circumferential folds

Question 18

how is an incomplete prolapse treated

Answer 18

children- dietary advice and treatment for constipation

adults- treatments similar to haemorrhoids

Question 19

what is an anal fissure

Answer 19

tear in the anal margin due to passage of constipated stool

Question 20

where do anal fissure usually happen

Answer 20

midline posteriorly, can be anterior

Question 21

what might cause multiple fissures

Answer 21

crohns diease

Question 22

how do anal fissures present

Answer 22

acute onset of severe anal pain, usually following episode of constipation (pooing glass), pain lasts for up to 1/2 ours after defecation, bright rectal bleeding

Question 23

how are anal fissures treated

Answer 23

dietary advice, stool softeners,
pharmacological sphyncterotomy,
lateral sphyncterotomy,
botox injection

Question 24

what is a fistula

Answer 24

abnormal communication between two epithelial surfaces

Question 25

what is a fitsula in ano

Answer 25

internal opening in anal canal and one or more external openings on the peri anal skin

Question 26

what can rarely cause fistula in ano

Answer 26

crohns, TB and carcinoma

Question 27

what usually causes a fistula in ano

Answer 27

usually arise from delay in treatment or inadequate treatment of anorectal abscess

Question 28

what investigations should be done into fitsula in ano

Answer 28

exam under anaesthesia of ano rectum

rigid sigmoidoscopy, proctoscopy,

flexible sigmoidoscopy,

MRI

Question 29

how are anal fistulas managed

Answer 29

lay open procedure ( cuts fistula open and heals from inside out)

insertion of a cutting seton (if fistula large through sphincter this tube will gradually cut through the sphincter healing it as it goes)

LIFT procedure (ligation of intersphincteric fistula tract)

glue/ permacol

defunctioning colostomy

Question 30

what are the complications of a fistula in ano

Answer 30

pain, bleeding, incontinence of flatus or stool, recurrence, further surgery