Perianal Surgery Flashcards Preview

Year 3 Lower GI Surgery > Perianal Surgery > Flashcards

Flashcards in Perianal Surgery Deck (24)
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1
Q

Haemorrhoids pathophysiology

A

Disrupted and dilated anal cushions

• Gravity, straining → engorgement and enlargement of
anal cushions

• Hard stool disrupts connective tissue around
cushions.

• Haemorrhoids arise above dentate line - not painful

2
Q

Presentation of haemorrhoids

A
• Fresh painless PR bleeding
- Bright red
- On paper or stool 
• Pruritis 
• Lump in perianal area
• Severe pain = thrombosis
3
Q

Haemorrhoid Investigation

A
  • Full abdo exam
  • Inspect perianal area: masses, recent bleeding
  • DRE: can’t palpate piles unless thrombosed
  • Rigid sig to identify higher rectal pathology
  • Proctoscopy
  • Anaemia - FBC and a coagulation screen
4
Q

Mx of haemorrhoids

A

Conservative:
• ↑ fibre and fluid intake
• Stop straining

Medical:
• Topical 
- Anusol: hydrocortisone + lidocaine
- Analgesics
• Laxatives: lactulose or fybogel
Interventional:
• Injection with sclerosant
• Banding → thrombosis and separation
• Cryotherapy
• Infra-red coagulation

Surgical:
Haemorrhoidal artery ligation

Haemorrhoidectomy - Excision of piles + ligation of vascular pedicles

• Discharge with laxatives post-op

5
Q

Side effects of haemorrhoidectomy

A

Bleeding, infection and stenosis

6
Q

Mx of thrombosed piles

A
  • Analgesia
  • Ice-packs
  • Stool softeners
  • Topical lignocaine jelly
  • Pain usually resolves in 2-3wks
  • Haemorrhoidectomy is not usually necessary
7
Q

Anal fissure

A

Tear of squamous epithelial lining in lower anal canal

8
Q

Causes of anal fissure

A

• Hard stool
- Assoc. with constipation

• Rarer causes, often → multiple ± lateral fissures

  • Crohn’s
  • Herpes
  • Anal Ca
  • Trauma
9
Q

Presentation of anal fissure

A

• Intense anal pain especially on defecation

• Fresh rectal bleeding
- On paper

• pruritis

Examination:
• PR often impossible
• Groin LNs suggest complicating factor: e.g. HIV

10
Q

Management of anal fissure

A

Conservative:
• Soaks in warm bath
• Toileting advice
• Dietary advice: ↑ fibre and fluids

Medical:
• Laxatives: lactulose + fybogel
• Topical:
- Lignocaine
- GTN ointment
- Diltiazem cream CCB

• EUA + botulinum toxin injection

Surgical: Lateral partial sphincterotomy
• Pre-op anorectal US and manometry

11
Q

If recurrent, chronic anal fissure

A

EUA is done

12
Q

Complications of sphincterotomy

A
  • Minor faecal/flatus incontinence (= GTN)

- Perianal abscess

13
Q

Pilonidal Sinus

A

Ingrown hair causes foreign body reaction → formation of abscess

14
Q

Anal Carcinoma

A

Squamous cell carcinoma (80%)

• Spread

  • Above dentate line → internal iliac nodes
  • Below dentate line → inguinal nodes
15
Q

Rectal prolapse

A

Protrusion of rectal tissue through the anal canal

16
Q

Mx of rectal prolapse

A

Partial Prolapse:
• Phenol injection
• Rubber band ligation
• Surgery: Delorme’s Procedure

Complete Prolapse
• Conservative
- Pelvic floor exercises
- Stool softeners

• Surgery

  • Abdominal Approach: Rectopexy
  • Lap or open
  • Mobilised rectum fixed to sacrum with mesh
  • Perineal Approach: Delorme’s Procedure
17
Q

Delorme’s Procedure

A

Resect mucosa and suture the two mucosal boundaries

18
Q

Classification of haemorrhoids

A

1st Degree: Remain in the rectum

2nd Degree: Prolapse through the anus on defecation but spontaneously reduce

3rd Degree: Prolapse through the anus on defecation but require digital reduction

4th Degree: Remain persistently prolapsed

19
Q

Risk factors of haemorrhoids

A

Chronic constipation

Increasing age

Raised intra-abdominal pressure:

  • pregnancy
  • chronic cough
  • ascites
20
Q

Complications of haemorrhoids

A

Thrombosis
Ulceration or gangrene (secondary to thrombosis)
Skin tags
Perianal sepsis.

21
Q

What is the first line management for symptomatic 2nd degree haemorrhoids?

A

Haemorrhoidal artery ligation

22
Q

anorectal abscesses mx

A

Incision and drainage

Protoscopy once drained to check for fistula

23
Q

Risk factors for anal fissures

A

Constipation
Dehydration
Inflammatory bowel disease
Chronic diarrhoea

24
Q

Investigations of anal fissures

A

DRE - may need examination under anaesthesia

Proctoscopy