Podcast
Questions and Answers
Which treatment involves cutting off the blood supply to hemorrhoids?
Which treatment involves cutting off the blood supply to hemorrhoids?
- Open hemorrhoidectomy
- Banding (correct)
- Sclerotherapy
- Stapled hemorrhoidopexy
Sclerotherapy is performed below the dentate line.
Sclerotherapy is performed below the dentate line.
False (B)
What is the primary purpose of a sitz bath in the management of hemorrhoids?
What is the primary purpose of a sitz bath in the management of hemorrhoids?
To relax the sphincter
Grade 4 hemorrhoids generally require __________.
Grade 4 hemorrhoids generally require __________.
Match the following hemorrhoid management techniques with their descriptions:
Match the following hemorrhoid management techniques with their descriptions:
What is the length of the rectum?
What is the length of the rectum?
The proximal part of the anal canal is covered by peritoneum.
The proximal part of the anal canal is covered by peritoneum.
Which of the following is considered a risk factor for squamous cell carcinoma of the anal cancer?
Which of the following is considered a risk factor for squamous cell carcinoma of the anal cancer?
What nerve supplies the external sphincter?
What nerve supplies the external sphincter?
Adenocarcinoma of the anal region is the most common type of anal cancer.
Adenocarcinoma of the anal region is the most common type of anal cancer.
The area above the dentate line is associated with __________ carcinoma.
The area above the dentate line is associated with __________ carcinoma.
Match the components of the anal canal with their characteristics:
Match the components of the anal canal with their characteristics:
What is the purpose of MRI in the management of anal cancer?
What is the purpose of MRI in the management of anal cancer?
The treatment regimen for anal squamous cell carcinoma includes combined ____ and _____ prior to surgery.
The treatment regimen for anal squamous cell carcinoma includes combined ____ and _____ prior to surgery.
Match the treatment response with its description:
Match the treatment response with its description:
Which finger is typically used for a digital rectal examination in adults?
Which finger is typically used for a digital rectal examination in adults?
A digital rectal examination is contraindicated if there are painful fissures present.
A digital rectal examination is contraindicated if there are painful fissures present.
What is the purpose of using an anoscope during a rectal examination?
What is the purpose of using an anoscope during a rectal examination?
The __________ is approximately 110-140 cm in length and visualizes from the anal canal to the cecum.
The __________ is approximately 110-140 cm in length and visualizes from the anal canal to the cecum.
Match the following instruments with their lengths:
Match the following instruments with their lengths:
What is the most common complication following a hemorrhoidectomy?
What is the most common complication following a hemorrhoidectomy?
Anal fissures are typically found above the dentate line.
Anal fissures are typically found above the dentate line.
What are two clinical features of anal fissures?
What are two clinical features of anal fissures?
A high fiber diet is recommended for managing __________.
A high fiber diet is recommended for managing __________.
Match the following treatments to their descriptions:
Match the following treatments to their descriptions:
Which drug is included in the FOL FIRI regimen?
Which drug is included in the FOL FIRI regimen?
Radiotherapy is indicated for colonic cancer.
Radiotherapy is indicated for colonic cancer.
What is the minimum functional liver reserve required for resection in colorectal carcinoma management?
What is the minimum functional liver reserve required for resection in colorectal carcinoma management?
The primary function of Bevacizumab in colorectal cancer treatment is as an __________ inhibitor.
The primary function of Bevacizumab in colorectal cancer treatment is as an __________ inhibitor.
What is the most common cause of rectal bleeding?
What is the most common cause of rectal bleeding?
Match each drug with its corresponding function for colorectal cancer treatment:
Match each drug with its corresponding function for colorectal cancer treatment:
Bleeding from hemorrhoids is typically painful.
Bleeding from hemorrhoids is typically painful.
What is the investigation of choice for diagnosing hemorrhoids?
What is the investigation of choice for diagnosing hemorrhoids?
Grade 2 hemorrhoids are characterized by prolapse that is __________.
Grade 2 hemorrhoids are characterized by prolapse that is __________.
Match the grades of hemorrhoids with their features:
Match the grades of hemorrhoids with their features:
Which of the following is NOT a clinical feature of an anorectal abscess?
Which of the following is NOT a clinical feature of an anorectal abscess?
Fluctuation is an early sign of an anorectal abscess.
Fluctuation is an early sign of an anorectal abscess.
What is the common management technique for an anorectal abscess?
What is the common management technique for an anorectal abscess?
The condition characterized by an external and internal opening is known as a __________.
The condition characterized by an external and internal opening is known as a __________.
Match the causes of perianal sinus/fistula with their descriptions:
Match the causes of perianal sinus/fistula with their descriptions:
What is the primary purpose of Goodsall’s rule in fistula management?
What is the primary purpose of Goodsall’s rule in fistula management?
High fistulas are appropriately managed by performing a fistulectomy.
High fistulas are appropriately managed by performing a fistulectomy.
What are the two management options for low fistulas?
What are the two management options for low fistulas?
A transsphincteric fistula is the most __________ type of fistula.
A transsphincteric fistula is the most __________ type of fistula.
Match the types of fistula-in-ano with their descriptions:
Match the types of fistula-in-ano with their descriptions:
What is the primary feature that differentiates pilonidal sinus disease between genders?
What is the primary feature that differentiates pilonidal sinus disease between genders?
Anal advancement flap is a surgical procedure used primarily for managing hemorrhoids.
Anal advancement flap is a surgical procedure used primarily for managing hemorrhoids.
List two clinical features of pilonidal sinus disease.
List two clinical features of pilonidal sinus disease.
Pilonidal sinus disease can lead to _______ and _______ due to inward growth of hair.
Pilonidal sinus disease can lead to _______ and _______ due to inward growth of hair.
Match the type of surgical technique with its description:
Match the type of surgical technique with its description:
Study Notes
Grade 1 Hemorrhoids
- Lifestyle changes: Increase high fiber diet, increase liquid intake, avoid fried/fatty/spicy food.
- Laxative use.
- Sitz bath: Warmwater relaxes the sphincter.
Grade 2 Hemorrhoids
- Management is similar to Grade 1 plus:
- Banding
- Cuts off blood supply.
- Hemorrhoid sloughs off.
- Performed above dentate line
- Sclerotherapy
- Performed above dentate line.
- Sclerosing agents pull hemorrhoids up.
- Sloughs them off.
- Common sclerosing agents include:
- Sodium tetradecyl sulfate
- Sodium morrhuate
- Polidocanol
- Phenol in almond oil
- Complications:
- Deep sclerotherapy can cause Pain, Infection, Prostatitis (anteriorly).
- Banding
Grade 3 Hemorrhoids
- Management includes Grade 2 treatment options plus surgery.
Grade 4 Hemorrhoids
- Requires surgery.
Hemorrhoid Surgery
- Types:
- Open hemorrhoidectomy (Milligan-Morgan) (obsolete)
- Closed hemorrhoidectomy (Ferguson)
- Stapled hemorrhoidopexy (preferred method)
- Doppler guided hemorrhoidal artery ligation (DGHAL)
Anal Cancer
- Most common type: Squamous Cell Carcinoma
- Risk Factors:
- Human papilloma virus
- HIV
- Homosexual individuals (more common in men than women)
- Clinical Features:
- Mass
- Bleeding
- Risk Factors:
- Adenocarcinoma: Uncommon
- Treatment: Similar to rectal cancer if less than 5 cm from anal verge.
Staging and Treatment for Anal Cancer
- Initial evaluation (IOC): Biopsy
- MRI: Used for local staging
- Nigro Regime:
- Combination chemotherapy and radiation therapy
- Administered 1-month prior to surgery
- Radiation therapy + Chemotherapy: 5-FU & mitomycin C (used for downstaging)
Anal Cancer Response to Treatment
- Complete response.
- Monitoring required (40-30%)
- Recurrence: Abdomino-Perineal Resection
- Residual tumor (within 5 cm): Further treatment needed.
Rectum and Anal Canal Anatomy
- Rectum length: 12-14 cm
- Upper and lower rectum: Convex towards the right
- Middle rectum: Convex towards the left
- Lower rectum: Not covered by peritoneum.
- Applied Anatomy: Resection of rectum below the peritoneum requires a low anterior resection.
Anorectal Ring
- Formed by levator ani muscle.
- Located 2-2.5 cm above the dentate line (no pain sensation)
- Located 2-2.5 cm below dentate line (pain sensation)
Dentate Line
- Anal verge
- Sphincters:
- Injury leads to incontinence.
Anal Canal
| Region | Epithelium | Applied Aspect |
|---|---|---|
| Proximal to dentate line | Columnar | Adenocarcinoma |
| Distal to dentate line | Modified squamous | Squamous cell carcinoma |
- Mucosa above the dentate line.
- Communication between crypts and anal glands: Site of abscess
- Submucosa in distal anal canal: 3 hemorrhoidal cushions/vascular channels
- Left anterior
- Right anterior
- Right posterior
Nerve Supply of the Anal Canal
- Internal sphincter innervation:
- Sympathetic: L5
- Parasympathetic: S2, S3, S4
- External sphincter innervation:
- Pudendal nerve (S2, S3, S4)
- Bilateral injury: Incontinence
- Unilateral injury: No incontinence
- Pudendal nerve (S2, S3, S4)
- Sacral promontory nerve.
- Injury: Ejaculatory & bladder dysfunction.
Rectal Examination (DRE)
- Position: Sims or Left lateral position.
- Obtain informed consent.
DRE Inspection
- Look for:
- External fistula opening
- External hemorrhoids
- Fissures (Painful - Contraindicated for DRE)
- Growths
DRE Technique
- Digit used:
- Adults: Index finger
- Children: Little finger
- Regions to examine:
- Anterior (12 o'clock): Males - Prostate, Females - Cervix, Pouch of Douglas
- Posterior (6 o'clock): Sacral hollow
- Lateral wall (3 o'clock)
Visualization Tools
- Anoscope: ~10 cm
- Proctoscope: ~13 cm
- Sigmoidoscope: 60 cm in length, visualizes until sigmoid colon.
- Colonoscope: 110-140 cm in length, visualizes from anal canal to cecum.
Colorectal Polyps and Cancer (Part 2)
Chemotherapeutic Regimens
- FOLFOX:
- 5-Fluorouracil (5-FU)
- Folinic acid
- Oxiplatinum
- FOL FIRI:
- 5-FU
- Folinic acid
- Irinotecan
Radiation Therapy
- Indications:
- Rectal cancer (not for colonic cancer)
- Advanced rectal cancer: Neoadjuvant chemoradiation followed by surgery
- Advantages: Sphincter preservation
Radiation Therapy in Rectal Cancer
- Duration:
- Short course: 5-6 days
- Long course: Few weeks
- Intracavity radiotherapy: Papillon
Immunotherapy for Colorectal Cancer
- Indications: Metastasis (most common site: Liver)
| Drug | Function |
|---|---|
| Bevacizumab | Anti VEGF (Vascular growth factor inhibitor) |
| Cetuximab | Anti EGFR (Epidermal growth factor inhibitor) |
| Panitumumab | Anti EGFR |
| Pembrolizumab | PDLI inhibitor |
Liver Metastasis
- Occurs in 60% of colorectal carcinoma.
- Types: Synchronous (liver mets occur within 1 year of colorectal cancer diagnosis)
Liver Metastasis Management
- Resection:
- Improves survival.
- Indication: FLR (Functional liver reserve) > 25%
- Minimum liver reserve needed for rejuvenation
- Number of metastases is not a criteria for resection.
Rectum & Anal Canal Complications
Hemorrhoidectomy
- Urinary retention (most common) due to reflex retention caused by pain.
- Reactionary hemorrhage.
- Pain.
Hemorrhoids
- Thrombosis
- Fibrosis
- Ulceration
- Gangrene
- Portal pyemia
Anal Fissure
- Breach in anal epithelium.
- Below dentate line.
- Midline position: 6 o'clock (posterior midline), 12 o'clock (in obstructed labour).
Anal Fissure Clinical Features
- Pain.
- Bleeding per rectum.
Anal Fissure Investigation
- External Inspection (IOC)
- Digital Rectal Examination (DRE): Contraindicated
Skin Tag (Sentinel Pile)
- Seen with chronic fissures.
- Accumulation of lymphatics.
Anal Fissure Management
- Lifestyle Changes:
- High fiber diet.
- Increased fluid intake.
- Avoid fried/fatty foods.
- Sitz bath.
- Laxative.
Anal Fissure Medical Management
- Topical Medications:
- 2% Xylocaine jelly before/after defecation.
- Diltiazem cream.
- Nitrate gel (relaxes the sphincter).
- Side Effects: Headache, Hypertension.
Anorectal Abscess
- Infection of the anal glands leading to perianal abscess.
Anorectal Abscess Clinical Features
- Pain
- Fever
- Swelling
- Fluctuation (late sign)
Anorectal Abscess Management
- Incision and drainage.
- Poorly drained abscess can lead to Perianal sinus/fistula.
Perianal Sinus/Fistula
- Secondary to anal sepsis.
- Single or multiple fistulas.
- Two openings (internal opening connected to external opening).
- AKA Water-can perineum: due to multiple external openings.
Causes of Perianal Sinus/Fistula
- Crohn's disease
- Trauma
- Tuberculosis
- Cancer
- Immunocompromised
Perianal Sinus/Fistula Clinical Features
- Staining of underwear with pus.
- Pain
- Itching
Perianal Sinus/Fistula Examination
- External opening identified on inspection.
- Internal opening confirmed by DRE.
Diagram: Anorectal Abscess Types
- Anterior (12 o'clock position): Straight, radial tracts.
- Posterior: Curved tracts, open in the midline.
- Mnemonic for causes of fistulas: Krohn, Krush, Cancer, Koch's
- Goodsall's rule (illustrated in the diagram).
Hemorrhoids
- Dilated vascular channels
- Arterial bleeding
- Most common cause of rectal bleeding
Hemorrhoid Clinical Features
- Bleeding per rectum (usually painless).
- Painful bleeding can occur with:
- External hemorrhoids (below dentate line)
- Thrombosed hemorrhoids
- Constipation
Hemorrhoid Investigation
- Proctoscopy (preferred method).
Thrombosed Piles
- Meleney's 5 day self-healing lesion.
- Painful.
- Mass felt on DRE.
Thrombosed Piles Management
- Immediate surgery:
- Excision
- Evacuation of clot
- Conservative management:
- Healing within 5 days to a few weeks.
- May require definitive surgery.
Thrombosed Piles Investigation
- Proctoscopy
- DRE: Thrombosed piles are palpable (Hemorrhoids are not palpable).
Hemorrhoid Grades
| Grade | Features |
|---|---|
| 1 | Only bleed, don't prolapse |
| 2 | Prolapse, spontaneously reduced |
| 3 | Prolapse, manually reduced |
| 4 | Remain prolapsed |
Fistula Management
Active Space
- Goodsall's rule: Horse shoe fistula in a posterior fistula.
Fistula Investigation
- MR fistulogram: 10C, Park's classification: Based on MR fistulogram.
General Fistula Management Principles
- Eliminate all septic foci.
- Delineate the fistula tract anatomy.
- Preserve continence.
- Prevent recurrence.
Fistula Classification Based on Internal Opening
- Landmark: Anorectal ring.
- Above: High fistula
- Below: Low fistula
Low Fistula Management
- Fistulectomy: Removal of the entire fistula tract, cost-effective.
- Fistulotomy: Tract is opened and granulation tissue removed.
High Fistula Management:
- Fistulectomy: Can cause incontinence if performed in high fistulas (avoid if possible).
- Ligation of fistulous tract (LIFT): Sphincter-preserving surgery.
- Video-assisted fistula therapy (VAFT): Fistula is coagulated through endoscopy.
Types of Fistula-in-ano
- Intersphincteric fistula
- Transsphincteric fistula (most common)
- Suprasphincteric fistula
- Extrasphincteric fistula
Pilonidal Sinus (Jeep Driver's Disease)
Pilonidal Sinus Surgical Management
- 1. Lateral Anal Sphincterotomy:
- Internal sphincter is cut → incontinence.
- External sphincter cutting → Fissure heals.
- Sphincter relaxes → Fissure heals.
- 2. Anal Advancement Flap.
Pilonidal Sinus Locations
- Natal cleft (most common).
- Interdigital area (seen in barbers).
- Face.
Pilonidal Sinus Characteristics
- More common in males.
- Hairy men.
- Caused by friction leading to inward hair growth → Abscess & sinus.
Pilonidal Sinus Clinical Features
- Pain
- Swelling
- Discharge
Pilonidal Sinus Management
- Antibiotics
- Analgesics
- Drain abscess, remove hair (to prevent recurrence).
Surgical Procedures for Pilonidal Sinus
- Incision lateral to midline.
- Surgery:
-
- Rhomboid/Limberg flap
-
- Bascom's technique
-
- Karydakis technique
-
Pilonidal Sinus Procedures
- Sinus cleared
- Sutured
- Bascom's technique
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Description
This quiz covers the various grades of hemorrhoids and their management options, including lifestyle changes, medications, and surgical interventions. Learn about treatment differences from Grade 1 to Grade 4 hemorrhoids, including techniques like banding and sclerotherapy.
