PROCTOLOGICAL DISORDERS

Question 1

What are hemorrhoids?

Answer 1

Peak between ages 45-65 and no difference between sexes.

There are highly specialized vascular cushions located in the submuscular space of the anal canal above the dentate line. There is displacement of the anal cushions due to dilation enlargement of the internal venous plexus. Real hemorrhoids are internal.

There are three prominent cushions from which hemorrhoids can develop. They typically occur due to increased pressure in anal canal, rectal redundancy and congestion of vascular components.

Symptoms include bleeding, prolapse, discharge, itching, pain in complicated cases and anemia due to bleeding.

Question 2

What are external hemorrhoids?

Answer 2

They are not true hemorrhoids. They arise from a different structure located around the anal verge which is composed of veins and covered by sensitive skin.

Question 3

What is the golgher classification?

Answer 3

It considers 4 grades of hemorrhoids based on the degree of prolapse. Only grade 3 and 4 require surgery.

Question 4

Treatment of hemorrhoids?

Answer 4

After proper diagnosis by anorectal examination :

1st line —> medical treatment with ointments, topical steroids, topical venotonic drugs + high fiber diet, stool softener, analgesics.

2nd line —> surgery.
- For low grade —> rubber band ligation, infrared photocoagulation, sclerotherapy.
- For high grade or recurrent —> excisional hemorrhoidectomy, hemorrhoidal artery ligation.

Question 5

What is the STARR procedure?

Answer 5

Stapled Trans Anal Rectal Resection, it is a minimally invasive procedure used to treat certain types of rectal prolapse and obstructed defecation syndrome.

Question 6

What is an anal fissure?

Answer 6

It is an unnatural fissure in the anus, usually extending from the anal opening and located posteriorly in the midline.
Mainly due to stretching of the anal mucosa beyond its capability like due to stretching to defecate, sever chronic constipation, chrons, ulcerative colitis, trauma.

Symptoms include pain during defecation, blood on stool, burning.

Question 7

Treatment of anal fissures?

Answer 7

1st line —> medical with topical anti inflammatory agents, stool softener, high fiber diet. In case of chronic cases nitroglycerine ointment.

2nd line —> botox or internal lateral sphincterotomy.

Question 8

What are anal fistulas?

Answer 8

It is an abnormal opening on the cutaneous surface near the anus. It is because there is an abnormal connection between the epithelialized surface of the anal canal and the perianal skin. Usually this is from a local crypt abscess.

Symptoms include pain, discharge, pruritus, systemic symptoms in abscess becomes infected.

Question 9

Classifications of anal fistulas?

Answer 9

Parks classification is bases on anatomy and their relationship to the sphincter complex : superficial, inter, trans, Supra, or extra.

American gastroenterological association classification is bases on two types : Simple characterized by a low single external opening with no perianal abscess. Complex has a high origin, multiple openings and often is associated to a perianal abscess.

Question 10

Treatment of anal fistulas?

Answer 10

The ONLY way to assess the fistula tract is in the OR with examination under anesthesia otherwise the patients would be in too much pain. Before doing so it is suggested to do an MRI with contrast inside the fistula tract to know exactly the path and the type of fistula.

If asymptomatic do nothing otherwise we can place a drainage, surely to cut open the fistula or fibrin glue injection.

Question 11

Perianal disease in IBD?

Answer 11

IBD comprehends:
- Ulcerative colitis which causes swelling and ulcers in your large intestine. It usually starts in your rectum and can spread to part or all of your colon.
- Chron disease which disease causes ulcers in your GI tract. It can affect any part of your GI tract, from your mouth to your anus, but it typically develops in your small intestine and the upper part of your large intestine.

Question 12

What is perianal chron disease?

Answer 12

Individuals with perianal fistulizing chrons disease experience a more challenging conditions due to a substantial decrease in QOL.
Presents with skin tags, multiple fistulas, fissures and abscesses.

Treatment :

1st line —> medical therapy based on antibiotics if proctitis + thiopurine and anti TNF.

2nd line —> surgery after drainage seton placed like fistulotomy, fistula laser closure, stem cells.

Question 13

What are rectocele?

Answer 13

It is a prolapse of the rectum into the vagina.
Can cause vaginal deliveries, history of constipation, chronic staining with bowel movements, rectal pain, stuck stools, painful sexual intercourse.

1st line —> medical therapy with high fiber diet and supplements, hydration, pelvic floor exercises, stool softener.

Surgery only in cases who do not resolve and affect QOL. Then we can so the STARR or rectoplexy (e rectum is mobilized and fixed posteriorly to the sacrum with a mesh).