Anal Problems

My general approach for bottom problems seems quite accurate - laxatives and home with GP follow up or admit because they're poorly.

e-LfH
http://www.enlightenme.org/knowledge-bank/cempaedia/lower-gastrointestinal-haemorrhage
http://www.enlightenme.org/the-learning-zone/node/7100

Doctors.net
http://www.doctors.net.uk/ecme/wfrmNewIntro.aspx?moduleid=1502 - I'm sure this is a good module but I couldn't get past the pre-test.

BMJ Learning
Haemorrhoids - very useful overview about rectal problems. Would recommend completing.
Haemorrhoids in primary care - has a useful comparison but isn't as good as the above module.

FOAM

http://us.bp.api.bmj.com/best-practice/monograph/181/basics/classification.html
http://myemergencymedicineblog.blogspot.co.uk/2010/02/what-is-typical-course-of-disease.html
http://www.bmj.com/rapid-response/2011/11/01/hemorrhoids

http://www.bmj.com/content/327/7411/354?variant=pdf
http://gut.bmj.com/content/52/2/264.long
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003431.pub3/abstract
http://dtb.bmj.com/content/36/7/55.abstract
http://bestpractice.bmj.com/best-practice/monograph/644/treatment/step-by-step.html

http://blog.ercast.org/2011/01/perianal-abscess/
http://blog.ercast.org/2013/02/a-primer-on-butt-pus/
http://www.ozemedicine.com/wiki/doku.php?id=perianal_abscess
http://www.bmj.com/content/345/bmj.e6705
http://sobroem.com/2013/12/05/mini-conference-anorectal-abcesses/



The Bottom

 The bottom is quite a complicated structure. The dentate line is where the two types of epithelium meet. Above the dentate line (into the rectum) there is no feeling. Below the dentate line the anus is very painful. This is important when you try to understand the pathology.
The rectum is supplied by the terminal branches of the superior rectal artery.
Most problems are caused by lack of dietary fibre, when we start to strain too much. This can cause stretching of the epithelium, and engorgement of the rectal arteries.

Haemorrhoids


Internal Haemorrhoids: Are proximal to the dentate line and covered by insensate transitional epithelium.
External Haemorrhoids: Distal anal canal. Covered by sensate (therefore painful) skin.
Thrombosed Haemorrhoids: Painful for 72hours until clot gets absorbed. Seen like dark bluey purple lumps outside. Very very painful. Not reducible. Can be treated with rest, ice, analgesia and bed rest. After they have healed there is normally a sentinel skin tag externally.




Grade l - Internal haemorrhoids that may bleed but do not prolapse
Grade ll - Internal haemorrhoids that prolapse and reduce spontaneously
Grade lll - Internal haemorrhoids that prolapse and need manual reduction
Grade lV - Internal or external haemorrhoids that are prolapsed and cannot be manually reduced.



Most haemorrhoids can be managed conservatively:
- analgesia
- sits baths
- avoid constipation

Anal Fissures
- Conservative treatment (Local anaesthetic and dietary measures to avoid constipation)
- GTN Ointment (0.4%)
  Has more side effects (like headache) but is just as effective as diltiazem. 
- Diltiazem (2%)

A fissure is a longitudional tear in the anal skin, below the dentate line. They are most commonly found at the six o'clock position. The cause is not fully understood, but low intake of dietary fibre may be a risk factor.
They cause pain during and for 1-2 hours after defecation. A rectal examination is unlikely to be tolerated.

Peri-anal Abscesses
Antibiotics are not an alternative to surgical drainage of these abscesses and should be used as an adjunctive treatment for patients with diabetes, immuno-compromise, chronic debilitation, older age, history of cardiac valvular disease, or significant associated cellulitis.
Pilonoidal sinus' are caused by an ingrowing hair.

Summary of Haemorrhoids