ORAL QUESTIONS SENARIO 14 Questions about Piles (all what you need about Haemorrhoids) Q1. What is haemorrhoid? Answer: They are abnormally enlarged vascular mucosal cushions in the anal canal. These mucosal cushions are normal findings - they help to maintain anal continence.[1] It is only when they become enlarged and start to cause symptoms that they become haemorrhoids. Q2. Where they are originate? Answer: Haemorrhoids originate either above the dentate line (internal haemorrhoids) or below the dentate line (external haemorrhoids) Q3. You mention the the dentate line, what is it? Answer: The dentate line is 2 cm above the anal verge and is the anatomical delineation between the upper and lower anal canal. Q4. Could you please classify the haemorrhoids? Answer: !). Internal haemorrhoids Are classified according to the degree of prolapse, although this may not always reflect the severity of symptoms: 1. First-degree haemorrhoids (grade I): do not prolapse. 2. Second-degree haemorrhoids (grade II): prolapse on straining; reduce spontaneously. 3. Third-degree haemorrhoids (grade III): prolapse on straining; can be reduced manually. 4. Fourth-degree haemorrhoids (grade IV): permanently prolapsed; cannot be reduced. They are painless unless they become strangulated. This is because the upper anal canal has no pain fibres. !!). External haemorrhoids >. Lie under the perianal skin just inside and outside the anal verge below the dentate line. >. Are covered by squamous epithelium and have sensory innervation so may become painful and itchy. >. May be visible on external examination. Internal and external haemorrhoids can co-exist. Q5. How common they are? Answer: Prevalence is estimated at between 4% and 34% Q. 6 What are the risk factors to get haemorrhoids? Answer: >. constipation, >. prolonged straining and time on the toilet, >. increased abdominal pressure as in ascites or during pregnancy and childbirth, heavy lifting, chronic cough, ageing and hereditary factors. Q7. What are the symptoms patient may get from the haemorrhoids? Answer: Symptoms include: >. A person may be asymptomatic. >. Bright-red, painless rectal bleeding with defecation is the most common symptom. It may be streaks on the toilet paper or blood dripping into the toilet. Blood may coat stools but is not mixed in. >. Anal itching and irritation may result from chronic mucus discharge irritating the perianal skin. >. A feeling of rectal fullness, discomfort or of incomplete evacuation on bowel movements may be present if prolapse occurs with straining. >. Prolapsed haemorrhoids may present with a history of a lump at the anal verge. >. Soiling due to mucous discharge or impaired continence may also be experienced. >. Pain is rarely felt with internal haemorrhoids unless the haemorrhoid prolapses and becomes strangulated. >. Strangulated haemorrhoids may thrombose which is intensely painful. >. External haemorrhoids do not usually cause symptoms unless thrombosis occurs causing acute severe pain and a visible/palpable perianal lump. Q8. Could tell us what are the differential diagnosis causing symptoms like haemorrhoids ? Answer: . Anal carcinoma. . Colorectal cancer. . Inflammatory bowel disease: Crohns disease, ulcerative colitis. . Rectal prolapse. . Adenomatous polyps. . Anal fissure. . Condylomata acuminata (genital warts). . Anorectal abscess. . Anal fistula. . Other causes of pruritus ani - eg, threadworms, contact dermatitis. Q9. your are running today the clinic, and referral came to you with fresh PR bleed, how to investigate this patient Answer: well first of all I have to take history and do general examination and anorectal as well. well done talk to us about anorectal examination? to start with: inspection palpation next is to perform PR examination Good carry on Proctoscopy as well as rigid sigmoidoscopy should be carried out Q10. You finished your examination, and the patient has haemorrhoids How to manage it? Answer: Treatment depends on the degree of prolapse and the severity of symptoms. a). Prevention and management of constipation: >. Increase fluid and fibre intake. Aim for an intake of 25-30 g of insoluble fibre (raw fruits, vegetables, fibre supplements) and 6-8 glasses of fluid daily. Avoid too much caffeine. >. Bulk-forming laxatives such as ispaghula husk or sterculia are preferred if constipation needs treatment. Alternatives are lactulose or sodium docusate b). Pain and symptom relief: >. Simple analgesia - for example, paracetamol. Avoid constipating codeine analgesia. >. Topical therapies: . Anaesthetic preparations may alleviate pain, burning, and itching. They should be used for only a few days, as they may cause sensitisation of the anal skin. . Good perianal hygiene may be helpful in providing symptomatic relief and preventing perineal dermatitis. Moistened towelettes or baby wipes can be used to clean the perianal area. The area should then be patted dry. . Straining at stool should be avoided as it can make symptoms worse. Q11. Well the conservative treatment has failed. What are you going to do for the patient i.e how do treat him? Answer: Non-surgical treatments I am going to explain to the patient what I am going to do for his his or her haemorrhoids and the pros and cons of the procedure Good tell us : 1. Rubber band ligation: >. A band is applied to the base of the haemorrhoid which becomes necrotic after a few days and drops off. >. Up to three haemorrhoids can be banded at one time. >.A good treatment for grade II haemorrhoids with similar results to haemorrhoidectomy but without the same pain and other side-effects. >. There is a risk of haemorrhoid recurrence. >. Pain and haemorrhage are possible complications.The haemorrhage may be delayed (up to 5-10 days post-procedure). OR 2. Infrared coagulation/photocoagulation >.Infrared energy causes tissue fibrosis which leads to mucosal fixation and a reduced chance of the haemorrhoid prolapsing. OR 3. Injection sclerotherapy >.5% oily phenol is injected around the base of the haemorrhoids, leading to haemorrhoid atrophy because of fibrosis of blood vessels. >. Less effective than rubber band ligation. >. Not used in large prolapsing haemorrhoids. Bipolar diathermy; direct current electrotherapy (The heat applied causes tissue fibrosis. Not so widely used.) OR Bipolar diathermy; direct current electrotherapy The heat applied causes tissue fibrosis. (Not so widely used.) Q12. whats your choice of treatment? Rubber band ligation why Because I am confident using it and has less complication OR Injection sclerotherapy Q13 fair enough if these mode of treatment failed what is the next option? i.e.whats the indication of Haemorrhoidectomy? These are reserved for large, symptomatic haemorrhoids that do not respond to other treatments. Second , third, fourth degree haemorrhoid Type of operations: 1. Ferguson 2. Ligasure 3. Harmonic Scalpe 4. Procedure for Prolapse and Haemorrhoids (PPH; Stapled Haemorrhoidopexy) Haemorrhoidectomy (Ferguson) >. This is a painful procedure, performed under general anaesthesia. >. Several operative techniques have been described - eg, the Milligan-Morgan open haemorrhoidectomy. >. Excisional haemorrhoidectomy is more effective long-term than the less invasive technique of rubber band ligation, at least for grade III haemorrhoids, but at the expense of increased pain, higher complications and more time off work.[5] >. Complications can include infection, secondary haemorrhage, urinary retention, abscess formation, faecal incontinence, fistula and anal stenosis. Circular stapled haemorrhoidectomy >. This is a possible treatment for prolapsed, symptomatic internal haemorrhoids. >. A specialised circular stapling gun allows excision of a doughnut of mucosa from the upper anal canal. This interrupts the blood supply to the haemorrhoids and has the effect of pulling up the prolapsed mucosa. >. Seems to be less painful and allow a quicker return to usual activities and work than conventional haemorrhoidectomy. >. There is a higher rate of prolapse and re-intervention for prolapse compared with conventional haemorrhoidectomy. Haemorrhoidal artery ligation >. This involves cutting off the blood supply to the haemorrhoids, so shrinking them. >.The procedure is usually performed under general anaesthesia and a proctoscope and Doppler are used to visualise the haemorrhoidal arteries which are then sutured. Q13. If the haemorrhoids are thrombosed. what is your treatment? .These are extremely painful. . Consider admission for those presenting early, as some advocate excision under local anaesthetic. Incision and drainage of the clot relieve pain but the thrombosis often recurs and there may be persistent bleeding. , Conservative treatment includes analgesia, ice packs and stool softeners. A topical calcium antagonist may help to relieve pain.[2] , If managed conservatively, symptoms usually settle within 10-14 days. Q14. What is the complications? Answer: . Skin tags can develop because of repeated haemorrhoid dilatation which causes the overlying skin to enlarge and stretch. . Ischaemia, thrombosis and even gangrene may develop when internal haemorrhoids become strangulated. . Perianal sepsis may occur but is rare. . Severe or persistent bleeding may lead to anaemia. . Thrombosed external haemorrhoids may ulcerate. Prognosis . Is generally good. . Conservative measures are adequate for many people. . About 10% of people will eventually need surgery. . Haemorrhoids in pregnancy usually resolve after delivery.
Posted on: Wed, 29 Oct 2014 18:40:15 +0000
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