Benign conditons of the ano-rectal area

Question 1

What is a haemorrhoid?

Answer 1

Enlarged vascular cushions in the lower rectum and anal canal

Question 2

What is the classic presentation of haemorrhoids?

Answer 2

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

Question 3

What is the classical positioning of haemorrhoids?

Answer 3

corresponds to the branches of the superior haemorrhoidal artery occuring at 3 , 7 and 11 o’clock position

Question 4

What are the investigations for heamorrhoids?

Answer 4

PR examination
Rigid sigmoidoscopy
Proctoscopy
Flexible sigmoidoscopy in patients above age of 50

Question 5

What is the best procedure for symptomatic haemorrhoids?

Answer 5

HALO (haemorrhoidalartery ligation operation) or

THD (transanal haemorrhoidal dearterialisation)

Question 6

Describe the HALO procedure?

Answer 6

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

Question 7

What is a rectal prolapse?

Answer 7

Protruding mass from anus especially during defecation - bleeding and mucus

Examination usually shows poor anal tone

Question 8

What are the two kinds of rectal prolapse?

Answer 8

Partial

Complete

Question 9

What is the best treatment for complete rectal prolapse?

Answer 9

Abdominal rectopexy

Question 10

What is the best treatment for complete rectal prolapse in a frail patient?

Answer 10

bulking agent and education on manual reduction

Question 11

Describe anal fissures?

Answer 11

Tear in the anal margin due to passage of a constipated stool
Usually in the midline posteriorly but may be occasionally anterior

Question 12

What may multiple fissures be due to?

Answer 12

Crohn’s disease

Question 13

What is the clinical presentation of anal fissures?

Answer 13

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 14

What is the treatment anal fissures?

Answer 14

Dietary advice, stool softeners
Pharmacological sphyncterotomy (0.3% GTN ointment, 2% Diltiazem ointment)
Lateral sphyncterotomy
Botox injection

Question 15

What is a fistula in ano?

Answer 15

Abnormal communication between two epithelial surfaces

There is an internal opening in the anal canal and one or more external openings on the peri-anal skin

Question 16

What conditions can cause a fistula in ano?

Answer 16

Crohn’s disease
tuberculosis
carcinoma

Question 17

How do fistulas in ano arise?

Answer 17

Majority arise from delay in treatment, or inadequate treatment of anorectal abscess

Question 18

What are the recommended investigations and treatmetns for fistulas in ano?

Answer 18

MRI
Insertion of Seton (draining, cutting)
LIFT procedure
Glue/permacol
Defunctioning colostomy