Ano-rectal Disorders

Question 1

Give examples of ano-rectal diseases

Answer 1

Haemorrhoids
Fisssure in ano
Fistula in ano
Solitary rectal ulcer
Chronic anal pain

Question 2

What history suggests haemorrhoids ?

Answer 2

Pain (not severe)
Blood, pus, mucus (mucus esp if external)
Staining in underwear
Ask about continence
Obstetric history
Anything coming out?
Tenesmus
Itch

Question 3

What are haemorrhoids ?

Answer 3

Swollen and inflamed veins in the anus and lower rectum that cause discomfort, itching, and bleeding
-occur when the veins in this area experience high pressure; pushing, straining, increased intraabdominal pressure etc

aka piles

Question 4

What are the two types of haemorrhoids ?

Answer 4

Internal
-Distension of anal cushion venous plexuses, drain to superior rectal vein
-Anal cushions are submucosal structures of anal canal with role in continence, highly vascularised
-Can prolapse out
-Above dentate line

External
-Distention of venous plexuses which drain into inferior rectal veins
-Are out by default
-Below dentate line

Purple are internal, blue are external

Question 5

How are haemorrhoids graded ?

Answer 5

1 bleeding not out
2 bleeding in and out themselves
3 bleeding push back in
4 bleeding and out all the time

Question 6

How is treatment of haemorrhoids approached ?

Answer 6

They usually get better by themselves after a couple of days

Conservative treatments and measures are essential:
-Diet & Lifestyle changes (it is a lifestyle disease)
-Topical drugs

Outpatient interventions:
-Banding
(nobody uses sclerotherapy anymore)

Best treament is to not hold in bowel movement; teachers get them oft

Treatment rarely surgical

Question 7

What are do’s when it comes to manging haemorrhoids ?

Answer 7

Question 8

What are don’t when treating haemorrhoids ?

Answer 8

Question 9

Outline use and limits of banding ?

Answer 9

Banding helps bleeding

Not good for itching and can cause scarring, not ideal for cosmetic appearance of anus

Question 10

What are common topical therapies for haemmorhoids ?

Answer 10

1) Anusol
-Containsastringent(s) and an emollient; good for bleeding

2) Germoloids
-Local anaesthetic (lidocaine) and astringent(s); pain and itch

3) Anusol HC plus
-Corticosteroid (hydrocortisone acetate) and astringent(s)
-Steroids good for itch but are short-term

Question 11

How long can steroids and local anaesthetic be used for in treating haemorrhoids ?

Answer 11

A few days max for local anaesthetic creams
7 days for steroids

Question 12

What are often misidentified ?

Answer 12

Skin tags often misidentified for e.g. haemorrhoids

Question 13

Why is surgery not that good for haemorrhoids ?

Answer 13

High haemorrhoid recurrence rates in absense of lifestyle changes as this is the cause

Question 14

What operations can be done for haemorrhoids ?

Answer 14

1) Doppler ultrasound guided suture of terminal branches of superior haemorrhoidal artery
-Terminated blood supply to bleeding pile
-Stiches above pectinatr line so not sore
-Doesn’t help cosmetics of prolapses
-Use in internal haemorrhoids

2) Ligasure haemorrhoidectomy
-Cut off haemorrhoids and seals tissue behind
-Not that sore
-Better for anus cosmetics as fixes prolapsing haeomorroids

Question 15

How is location of haemorrhoid described ?

Answer 15

Clock hands when patient in lithotomy position: on their back with raised legs
-2 o’clock = anterior (towards the pubis/genitals)
-6 o’clock = posterior (towards the coccyx)
-3 o’clock = patient’s left
-9 o’clock = patient’s right

E.g. Grade 4 at 12 o’clock

Question 16

How are acute haemorrhoid presentations treated ?

Answer 16

-Analgesia; topical or oral non-opiate
-Bed rest; pressure taken off
-Ice filled glove on pile when really acute, should go away after couple of hours
-Stool softeners

E.g. Thrombosed external haemorrhoid → very painful, tense swelling or Acute prolapse of internal haemorrhoids

Question 17

What should be avoided in managing acutely presenting haemorrhoids ?

Answer 17

Admitting them acutely
Giving them opiates
Operating on them acutely
-Don’t want to operate on big thrombosed prolapsed piles as removing them will discard lots of sphincter
-Also you just dont really operate on them much

E.g. Thrombosed external haemorrhoid → very painful, tense swelling or Acute prolapse of internal haemorrhoids

Question 18

What can a thrombosed external haemorrhoid be mistaken for ?

Answer 18

SSC
-But these go away in a couple of days
-Are very painful

Question 19

What is an Anal Fissure ?

Answer 19

Longitudinal tear in the anoderm that may deepen in chronic cases to expose muscle e.g. IAS
-Result in a sentinel tag and a hypertrophied anal papilla
-Seriously sore with minor bleeding (In contrast to haemorrhoids)

Agony, sore 0.5h after toilet, need to lie down after toilet, scream at toilet, bite hand to not scream

Question 20

What is usually used to differentiate acute and chronic anal fissures ?

Answer 20

Less than 8 weeks = acute
More than or equal to 8 weeks = chronic

Question 21

What position do anal fissures tend to present ?

Answer 21

-Posterior most of the time
-Occasionally anterior, more common in women, association with difficult vaginal deliveries
-Super rare laterally (think pathology e.g. Crohn’s, syphillis)

Posterior is 6 o’clock

Question 22

Explain pathophysiology of anal fissures

Answer 22

Fissure arises from combination of mechanical trauma and impaired healing.
1) Hard stool passage tears anoderm, most often midline posterior; relative poorly perfused “watershed area”
2) Pain from tear auses spasm of IAS, increases resting pressure compressing vessels reducing flow
3) Resulting ischaemia prevents healing; fissure persists and may deepen, sometimes exposing the underlying IAS.
4) Minor bleeding occurs because the anoderm is thin and vascular, so even a small tear can disrupt superficial vessels.

similar to squeezing knuckle makes it turn pale by forcing blood out

Question 23

What are conservative managements of anal fissures ?

Answer 23

Jaggy poos must be avoided (dont hold them in or else larger and more water absored from)
More fibre a day
Laxido
Stitz baths (good for fissures and haemmorhoids)

Natural history is that most of these heal (esp acute)

Question 24

What are Topical therapies for anal fissures ?

Answer 24

GTN (take paracetamol before for headache)
Diltiazem
Botox

All relax IAS to allow fissure healing

8 week courses

Question 25

Explain the use of botox in treating anal fissures

Answer 25

Chemical denervation of motor end plates decreases IAS pressure and increases blood flow -Helpful if poor compliance -Repeated treatments needed if lfestyle not adjusted (Recurrence can be as high as 50% at 2 years)

Question 26

What surgery could be done to treat anal fissures ?

Answer 26

Lateral Internal Sphincterotomy; cutting some IAS muscle fibres so reduce its resting pressure for fissure healing -Rarely done but especially not in women, particularly post-partum -Vaginal deliveries, episiotomies etc mean damage likely exists to EAS so dont want to weaken IAS

Question 27

How do Crohn's anal fissures present ?

Answer 27

Look awful often not sore

Question 28

What is a tag plasty ?

Answer 28

Removing skin tag

Question 29

When is anal fissuring very very concerning

Answer 29

In children -Children dont naturally get them -Think abuse

Question 30

What weird things can cause anal fissures ?

Answer 30

Syphilis, TB

Question 31

Outline the stepwise approach to treating anal fissures

Answer 31

1) Mandatory conservative measures -Baths, Soft stools, pain killers, lidocaine, obey the urge to stool 2) GTN or diltiazem if possible (8 weeks bd) 3) EUA and botox 4) Patient choice on next step: LIS/oral/flap

Question 32

What is an anal fistula ?

Answer 32

Fistula is an abnormal communication between two epithelial surfaces -Tube connecting inside of anal canal etc to adjacent to anus -Difficult to treat since transverses sphicner muscles -Associated absesses common along fistula route -Pierced ear counts as a fistula -They are leaky | Blues mark IAS and EAS, blue lines are common fistula routes

Question 33

How may a patient report a fistula ?

Answer 33

Spot on bottom which closes but then opens and produces pus etc and then closes

Question 34

How do anal fistulas develop ?

Answer 34

Mucus making glands around IAS produce mucus to help stool move -Glands can get blocked and rupture backwards; poo, pus, germs etc takes path of least resistance back and go down to form fistula

Question 35

How can fistulas be treated ?

Answer 35

Laying open Seton

Question 36

What is laying open ?

Answer 36

Cutting open abnormal tract to allow the wound to heal from the inside out -Like snipping from edge of ear to ear pierce hole -Great for small fistulas that are short and don’t involved sphincters -Skids and farts side effects, but often patients accept it as so fed up | Used to treat anal fistulas

Question 37

How much damage can male and female EAS take and still function normally ?

Answer 37

Female -Can cut out like 30% before problems Male -Can cut out like half before problems -Longer anal canal and stronger sphincter

Question 38

What is a seton ?

Answer 38

'Safety string' passes through the fistula tract, exits at both internal and external openings -Tied loosely or tightly -Keeps it open -Protects the sphincter -Buys time or treats gradually Seton encourages scarring over of canal!!!! Use in Crohn's fistulae

Question 39

How are anal fistulae investigated ?

Answer 39

EUA of anorectum Proctoscopy to visualise the opening of the tract MRI can be used in complex fistula | EUA = Examination under anaesthesia

Question 40

What is SRUS ?

Answer 40

Solitary rectal ulcer syndrome -Wasn’t a thing but nicorandil does this -But of pain and mucus discahrge -Seen in people with erratic bowel movements and disordered evacuation; holding for too long causes stook to rub on rectum and ulcerate -Straining, prolapse

Question 41

How can chronic anal pain be investigated ?

Answer 41

History Examine Proctoscopy Sigmiodoscopy EUA MRI

Question 42

How can chronic anal pain be managed ?

Answer 42

Amitryptiline at night -Tricyclic antidepressant Pain killers | Like 20-30 years of pain

Question 43

What are anal skin tags ?

Answer 43

Cosmesis concerns -Tends to be younger female patients concerned -Cosmetic surgeries not covered by NHS here Hygeine and wiping concerns in larger tags -Larger tags are abou thumb sized Seepage and leaking -Stool, mucus, or moisture -Not true incontinence | Are not == haemorrhoids

Question 44

Rare to do surgery first line for benign colorectal conditions Most things get better with time

Answer 44

Yup...