Case 14 - Anal fissures, haemorrhoids, IBD, perianal abcess, fistula

Question 1

what are haemorrhoids

Answer 1

enlarged anal vascular cushions

Question 2

why do haemorrhoids occur in pregnancy

Answer 2

most likely due to constipation, pressure from the baby in the pelvis and the effects of hormones that relax the connective tissue

Question 3

what are anal cushions

Answer 3

specialised submucosal tissue that contain connections between the arteries and veins, making them very vascular.

Question 4

what are anal cushions supported by

Answer 4

smooth muscle and connective tissue.

Question 5

what do anal cushions help to do

Answer 5

control anal continence, along with the internal and external sphincters

Question 6

what is the blood supply to anal cushions from

Answer 6

rectal arteries

Question 7

where are anal cushions usually located

Answer 7

3, 7, and 11 oclock

Question 8

what is a first degree haemorrhoid

Answer 8

no prolapse

Question 9

what is a fourth degree haemorrhoid

Answer 9

prolapsed permanently

Question 10

what are haemorrhoids often associated with

Answer 10

constipation and straining

Question 11

what is the common presentation of haemorrhoids

Answer 11

painless, bright red bleeding, typically on the toilet papaer or seen after opening the bowels

Question 12

in haemorrhoids, is the blood mixed with stool

Answer 12

the blood is not mixed with the stool, and if this is seen, it should make you think of an alternative diagnosis

Question 13

what are the other symptoms of haemorrhoids

Answer 13

sore/itchy anus
feeling a lump around or inside the anus

Question 14

what is visible on DRE for haemorrhoids

Answer 14

External (prolapsed) haemorrhoids are visible on inspection as swellings covered in mucosa

Internal haemorrhoids may be felt on a PR exam (although this is generally difficult or not possible)

They may appear (prolapse) if the patient is asked to “bear down” during inspection

Question 15

what is required for proper visualisation and inspection

Answer 15

Proctoscopy is required for proper visualisation and inspection. This involves inserting a hollow tube (proctoscope) into the anal cavity to visualise the mucosa

Question 16

what is the differential management for patients presenting with symptoms such as rectal bleeding

Answer 16

Anal fissures
Diverticulosis
Inflammatory bowel disease
Colorectal cancer

Question 17

what topical treatments are given for symptomatic relief and to help reduce swelling

Answer 17

Anusol (contains chemicals to shrink the haemorrhoids – “astringents”)

Anusol HC (also contains hydrocortisone – only used short term)

Germoloids cream (contains lidocaine – a local anaesthetic)

Proctosedyl ointment (contains cinchocaine and hydrocortisone – short term only)

Question 18

what does prevention and treatment of constipation involve

Answer 18

Increasing the amount of fibre in the diet
Maintaining a good fluid intake
Using laxatives where required
Consciously avoiding straining when opening their bowels

Question 19

what are the non-surgical treatments for haemorrhoids

Answer 19

Rubber band ligation (fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply)

Injection sclerotherapy (injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy)

Infra-red coagulation (infra-red light is applied to damage the blood supply)

Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it)

Question 20

what are the three surgical options for haemorrhoids

Answer 20

Haemorrhoidal artery ligation involves using a proctoscope to identify the blood vessel that supplies the haemorrhoids and suturing it to cut off the blood supply.

Haemorrhoidectomy involves excising the haemorrhoid. Removing the anal cushions may result in faecal incontinence.

Stapled haemorrhoidectomy involves using a special device that excises a ring of haemorrhoid tissue at the same time as adding a circle of staples in the anal canal. The staples remain in place long-term.

Question 21

what are thrombosed haemorrhoids caused by

Answer 21

strangulation at the base of the haemorrhoid, resulting in thrombosis in the haemorrhoid

Question 22

how do thrombosed haemorrhoids appear

Answer 22

purplish, very tender, swollen lumps around the anus

Question 23

how are thrombosed haemorrhoids treated

Answer 23

They will resolve with time, although this can take several weeks.

The NICE Clinical Knowledge Summaries (2016) suggests considering admission if the patient present within 72 hours with extremely painful thrombosed haemorrhoids. They may benefit from surgical management.

Question 24

what is an anal fissure

Answer 24

a tear in the skin that lines the anus below the level of the dentate line

Question 25

when will anal fissures be painful

Answer 25

on defecation

Question 26

what diseases are anal fissures associated with

Answer 26

Crohn’s and UC

Question 27

where do anal fissures usually occur

Answer 27

in the midline posteriorly

Question 28

what is common to find next to the lesion and what is it sometimes called

Answer 28

An oedemomatous skin tag is common next to the lesion. This is sometimes called a sentinel pile.

Question 29

why is examination of a fissure often difficult

Answer 29

due to pain and sphincter spasm

Question 30

what is the treatment of anal fissures

Answer 30

usually an anaesthetic cream and a stool softner

Question 31

what is given to aid relaxation of the internal sphincter

Answer 31

nitric oxide (GTN cream)

Question 32

what reduces anal sphincter tone, which in turn increases blood flow and promotes healing

Answer 32

2% diltiazem cream