What are haemorrhoids?
Enlarged symptomatic anal vascular cushions (not just dilated veins)
-Anal vascular cushions –> part normal anatomy, containing AV channels that connect superior rectal artery and vein, usually positioned 3, 7, 11 oclock. Can be smaller additional ones in haemorrhoids.
RF –> middle age, constipation w prolonged straining, pregnancy
What is the typical presentation of haemorrhoids?
What is the grading of haemorrhoids?
Bright red rectal bleeding –> on toilet paper and often coating stools, or dripping into toilet.
- There may be mucous discharge and pruritus ani.
- Usually painless, thrombosed external haemorrhoids can be painful and present acutely.
- Severe anaemia may occur.
- Symptoms such as weight loss, tenesmus, and change in bowel habit should prompt thoughts of other pathology.
Grading 1 Never prolapse 2 Prolapse and reduce spontaneously 3 Prolapse and require manual reduction 4 Irreducible
What are the investigations for haemorrhoids?
- DRE –> internal haemorrhoids can be hard to palpate
- Proctoscope for examining haemorrhoids –> examine colour and pain. Internal ask to strain and appear blue. Thrombosed painful and purple.
- In all rectal bleeding do –> An abdominal examination to rule out other diseases, PR exam: prolapsing piles are obvious. Internal haemorrhoids are not palpable. Colonoscopy/flexible sigmoidoscopy to exclude proximal pathology if >50 years old.
- FBC –> Check anaemia
How should haemorrhoids be managed?
What are the options?
1 –> 1st degree –> Medical –> -Reassure, avoid straining, soften stools (fibre and fluids, bulk). Topical local anaesthetic cream (short term)
2 –> Non operative –> 2 and 3 degree or 1st and medical not working –> Rubber band litigation (IMPORTANT) (not for external as normal sensory supply). Sclerosants (phenol oil). Infrared coag, coags vessels less painful. Bipolar diathermy and direct current electrotherapy causes coag and fibrosis.
3 –> Surgery –> Excisional haemorrhoidectomy is the most effective treatment (excision of piles ± ligation of vascular pedicles, as day-case surgery, needing ~2wks off work). Stapled haemorrhoidopexy (procedure for prolapsing haemorrhoids) may result in less pain, a shorter hospital stay, and quicker return to normal activity than conventional surgery.
-Prolapsed, thrombosed piles –> Analgesia, ice packs, and stool softeners. Pain usually resolves in 2–3wks. Some advocate early surgery.
What is appendicitis?
- Inflammation of the vermiform (worm shaped tube extending from caecum) appendix.
- Most commonly results from obstruction of appendiceal lumen –> usually secondary to a faecolith (hardened mass of faeces) obstruction w subsequent bacterial overgrowth leading to infection and pus formation(b frigilis, e.coli)
- Obstruction –> increase pressure of appendix –> compromise blood supply –> ischaemia, perforation, gangrene
- Lifetime risk 1 in 15
- RF –> constipation, younger age common in early teens
- Uncomplicated, non perforated. Complicated perforated.
What is the typical presentation of appendicitis?
- Anorexia commonly 1st sign, followed by abdo pain and vomiting.
- Abdo pain initially visceral colicky pain in umbilical region, then moves to RIF over 24-48 hours and becomes consistent.
- RIF pain –> inflammation affecting the tissue and peritoneum surrounding appendix.
- RIF peritonism –> pain on moving or coughing, guarding, rebound tenderness.
- Fever tends to be mild.
- Tenderness can be localised to mcburnies point
What are three potential signs in appendicitiis?
- Rovsings –> press in LIF and get RIF pain
- Psoas sign –> pain on extending hip (when retrocaecal appendix)
- Cope (obturator) sign –> pain on flexion and internal rotation of right hip
What are the differential diagnosis in appendicitis?
Meckels diverticulitis, , gastroenteritis, intussusception, crohns,
PID, ovarian cyst, ectopic pregnancy
UTI, renal colic
What are the investigations for appendicitis?
- Diagnosis –> most cases clinical.
- Bloods –> increased CRP and WBC.
- Diagnosis not sure or in older may have imaging
- Abdo pelvis CT –> best imaging often not required. US less sensitive but acceptable in pregnancy and children.
What is the management for appendicitis?
- Surgery –> appendectomy definitive. Laparoscopic fewer complications e.g abscess formation. In pregnancy open is safer.
- Ab before surgery and 24 hours after, urgently when perforated. Ab –> cover g+ve and –ve e.g coamoxiclav.
-Most cases of uncomplicated appendicitis resolve in 10 days w Ab alone but surgery performed as high risk recurrence w/o surgery, 25% within 1 year and 40% within 5 years.
What are the complications of appendicitis?
- Untreated can lead to perforation, generalised peritonitis and abscess formation
- Appendix mass, omentum and small bowel may adhere to inflamed appendix.
- Abscess can be treated w IV Ab and CT drainage. Abscess –> internal appendicectomy –> few weeks are intiial presentation following course Ab.
