L16: Benign Anorectal Conditions

Question 1

Examples of Benign Anorectal Conditions

Answer 1

Question 2

Anal Canal anatomy

Answer 2

Question 3

Def of Haemorrhoids (Piles)

Answer 3

Engorged displaced anal cushions.

Question 4

Anal cushion showing Treitz’s muscle contribution to anal pressure and maintain continence.

Answer 4

…

Question 5

Etiology of Haemorrhoids (Piles)

Answer 5

Question 6

Primary piles

Answer 6

▪ Hereditary congenital weakness of vein walls.

▪ Disruption of Treitz muscles due to chronic staining at stool.

Question 7

Secondary piles

Answer 7

▪ Pregnancy.

▪ Cancer rectum.

▪ Obstruction of venous return from anal cushions.
(It has no relation to portal hypertension)

Question 8

CP of Haemorrhoids

Answer 8

Question 9

Symptoms of Haemorrhoids

Answer 9

▪ Bright red bleeding at the end of defecation.

▪ Prolapse

▪ Mucoid discharge and pruritus

Question 10

Bleeding in Haemorrhoids

Answer 10

Bright red bleeding at the end of
defecation.

Question 11

Do Haemorrhoids Cause Pain?

Answer 11

Uncomplicated piles are painless

Question 12

Do Haemorrhoids Cause Anemia?

Answer 12

Piles rarely cause anemia

Question 13

Grades of Haemorrhoids

Answer 13

Question 14

Complications of Haemorrhoids

Answer 14

Question 15

Strangulation in Haemorrhoids

Answer 15

Piles are painful, purple, tender,
and tense.

Question 16

Thrombosis in Haemorrhoids

Answer 16

(after 12 h): Pain decreases, becomes solid, and marked edema of the anal margin develops.

Question 17

Gangrene in Haemorrhoids

Answer 17

Rarely complicated by severe anorectal sepsis and portal pyemia

Question 18

Thrombosed external piles

Answer 18

Question 19

Pain in Thrombosed external piles

Answer 19

Sudden severe pain that peaks within 48 hours.

Question 20

Characters of Thrombosed external piles

Answer 20

Purple black, tender, and tense perianal swelling.

Question 21

TTT of Haemorrhoids (Piles)

Answer 21

Question 22

TTT of Grade I & II Haemorrhoids (Piles)

Answer 22

Medical treatment for grade I & II and secondary piles.

Question 23

TTT of Garde II & III Haemorrhoids (Piles)

Answer 23

Rubber band ligation (RBL) for grade II & III piles.

Question 24

TTT of Grade III & IV Haemorrhoids (Piles)

Answer 24

Excision haemorrhoidectomy (EH) for grade III & IV piles or piles with skin tags

Question 25

Other Modalities in TTT of **Haemorrhoids (Piles)**

Answer 25

Question 26

Medical TTT of Haemorrhoids (Piles)

Answer 26

Question 27

RBL in TTT of Hemorrhoids

Answer 27

Question 28

In RBL, The band is applied to ..... above the pile.

Answer 28

mucosa

Question 29

In RBL, Two piles can be ligated at the same time (repeated after 2 weeks).

Answer 29

..

Question 30

In RBL, Sloughing occurs within .... days with slight bleeding.

Answer 30

7

Question 31

RBL is as effective as EH for grade .... piles has higher recurrence (50 % versus 20 %) for grade .... piles

Answer 31

II - III

Question 32

RBL is Contraindicated in patients with ......

Answer 32

bleeding tendency

Question 33

Revise Picture of Modalites used in TTT of Hemorrhoids

Answer 33

...

Question 34

What is the gold standard in TTT of Piles?

Answer 34

Excision haemorroidectomy

Question 35

RR in Excision haemorroidectomy

Answer 35

Lowest recurrence rate for grade III & IV piles (20%)

Question 36

Pain & Excision haemorroidectomy

Answer 36

Associated with sever postoperative pain

Question 37

Methods of **Excision haemorroidectomy**

Answer 37

Question 38

Complications of **Excision haemorroidectomy**

Answer 38

Bleeding, incontinence to flatus, anal stenosis, pain

Question 39

Algorithm of TTT of Piles

Answer 39

Question 40

Management of strangulated piles

Answer 40

Question 41

Managment of **Thrombosed external piles**

Answer 41

− < 48 h: Evacuation under local anesthesia. − > 48 h: Hot sitz baths and stool softners.

Question 42

def of **Anal Fissure**

Answer 42

A longitudinal tear in the anoderm in the anterior or posterior midline.

Question 43

Types of **Anal Fissure**

Answer 43

Can be acute or chronic (recurrent or persisting for > 6 ws).

Question 44

Etiology of **Anal Fissure**

Answer 44

Question 45

Causes of **Idiopathic anal fissure**

Answer 45

▪ Forceful dilatation of the anal canal by a firm stool. ▪ It persists due to pain induced spasm of the internal sphincter leading to mucosal ischemia.

Question 46

Causes of **Specific anal fissure**

Answer 46

perianal Crohn’s disease and sexually transmitted diseases.

Question 47

CP of **Anal fissure**

Answer 47

Question 48

Incidence of ****Anal fissure****

Answer 48

- It is common in young adult females. - It is not rare in infants and children.

Question 49

Pain in **Anal fissure**

Answer 49

Pain: Sharp and lasts for few hours.

Question 50

Examination of **Anal fissure** shows ....

Question 51

Characters of **Specific anal fissure**

Answer 51

▪ Ulcers with little pain, or non-healing. ▪ Ulcers off the midline or not related to the dentate line.

Question 52

TTT of **anal fissure**

Answer 52

Question 53

Aim in TTT of **anal fissure**

Answer 53

Complete relaxation of the internal sphincter.

Question 54

Medical TTT of **anal fissure**

Answer 54

Question 55

Botox in TTT of **anal fissure**

Answer 55

temporary paralysis for internal sphincter to allow healing.

Question 56

Partial internal sphincterotomy in TTT of Anal Fissure

Answer 56

When medical treatment fails or for recurrent or chronic anal fissure.

Question 57

def of **Chronic anal fissure**

Answer 57

persistent for > 1 month or with sentinel pile

Question 57

Complications of **Partial internal sphincterotomy**

Answer 57

Can cause permanent incontinence to flatus in 5 % of cases.

Question 58

Algorithm in TTT of Anal Fissure

Answer 58

Question 59

Types of **Rectal Prolapse**

Answer 59

1- Internal rectal prolapse. 2- External (complete) rectal prolapse.

Question 60

Def of **Internal rectal prolapse**

Answer 60

- Prolapse of the proximal rectum into rectal lumen during straining at defecation.

Question 61

Grades of rectal prolapse

Answer 61

Question 62

CP of **Internal rectal prolapse**

Answer 62

Question 63

Investigations for Internal rectal prolapse

Answer 63

Question 64

TTT of **Internal rectal prolapse**

Answer 64

1. Stapled transanal rectal resection (STARR). 2. Ventral mesh rectopexy

Question 65

Def of **Complete rectal prolapse**

Answer 65

- Protrusion of all layers of the rectal wall outside the anus. - Considered the end stage of rectal intussusception or internal rectal prolapse.

Question 66

Pathological Anatomy of Complete rectal prolapse

Answer 66

## Footnote − It is more common in old females usually associated with uterine prolapse. − In the Middle East it is more common in young males.

Question 67

Symptoms of **Complete rectal prolapse**

Answer 67

Question 68

Findings of Complete rectal prolapse on Examination

Answer 68

Question 69

Compare between Partial & Complete Rectal Prolapse in terms of - Incidence - Age - Layers - Length - Muscosa - Thickness - Contents - Continence

Answer 69

Question 70

TTT of **Rectal Prolaspse**

Answer 70

Question 71

TTT of **Rectal Prolaspse** - Abdominal Procedure

Answer 71

**a) Posterior rectopexy:** 1) Well’ operation. 2) Repstein operation. 3) Suture rectopexy. 4) Resection rectopexy. **b) Ventral mesh rectopexy**

Question 72

TTT of **Rectal Prolaspse** - Perineal Procedure

Answer 72

a) Delorme`s operation. b) Altemeier’s operation (perineal rectosigmoidectomy). c) Stapled transanal rectal resection (STARR). d) Thiersch's operation.

Question 73

Adv & Disadv of Abdominal procedures for rectal prolapse

Answer 73

Less recurrence but risk of injury to pelvic nerves and higher postoperative complication.

Question 74

Adv & Disadv of Perineal procedures for rectal prolapse

Answer 74

More safe but have more recurrence.

Question 75

What are other perineal procedures for rectal prolapse?

Answer 75

− STARR: Perineal proctectomy using staplers. − Thiersch's operation: Purse string narrowing of the anus around the index finger.

Question 76

Procedure of **Posterior rectopexy**

Answer 76

1. Complete mobilization of the rectum. 2. Rectum fixed to the sacrum by a mesh (e.g. Well s operation & Repstein s operation) or sutures (suture rectopexy). 3. Sigmoid resection can be added to suture rectopexy (resection rectopexy).

Question 77

SE of ****Posterior rectopexy****

Answer 77

▪ Recurrence: 5% ▪ Constipation: 70% ▪ Incontinence: improves in 70% of cases after several methos.

Question 78

Procedure of **Ventral mesh rectopexy**

Answer 78

1. Anterior dissection of the rectum till the pelvic floor. 2. A mesh strip is fixed to the rectum and sacral promontory.

Question 79

Advantages of Ventral mesh rectopexy

Answer 79

Avoids lateral dissection of the rectum so there is no postoperative constipation

Question 80

Procedure of **Delorme`s operation**

Answer 80

1. Excision of the mucosa covering the prolapsed part. 2. Longitudinal plication of the muscular rectal wall. 3. Mucosa to mucosa sutures.

Question 81

Disadvantages of **Delorme`s operation**

Answer 81

Recurrence: At least 20%. ▪ Safe operation. ▪ Constipation and incontinence improve.

Question 82

Procedure of **Altemeier`s operation**

Answer 82

1. Full thickness excision of the prolapsed rectum. 2. Coloanal anastomosis.

Question 83

SE of **Altemeier`s operation**

Answer 83

▪ Recurrence: 10%. ▪ Mortality: < 5%. ▪ Patient complains of low anterior resection syndrome. (Frequency − Urgency)

Question 84

The gold standard was ......

Answer 84

was posterior rectopexy then ventral mesh rectopexy

Question 85

Resection rectopexy: when there is associated slow transit

Answer 85

..

Question 86

Perineal procedures reserved for elderly patients with comorbidities, young males, and children.

Answer 86

..

Question 87

STARR: in small rectal prolapse or internal rectal prolapse.

Answer 87

..

Question 88

Thiersch's operation: For frail patients.

Answer 88

..

Question 89

Postanal repair for patients with incontinence.

Answer 89

..

Question 90

Done

Answer 90

..