Part 2: cases • • • • • differential diagnosis? must youconsiderinyour anal ,whatcommonconditions When apatientcomplainsofsevere Figure 75.1

symptoms. was otherwisewellandhadneverpreviouslyanybowel resultant hardstoolswasagonizing. worse. Nowhehadbecomeconstipatedandpassing the avoid evacuatinghisbowels, but thisjustmadethings paper.the lavatory Thepainwassobadthathetriedto accompanied by afewdropsofbright red bloodseenon timeheopenedhisbowels.Thiswasoften pain every revealed thathissymptoms were of6weeksexcruciating wastaken, this ‘painful piles’.Whenacareful history A 40-year-old man attendedtherectal clinic complaining of Case 75 Carcinoma of anal the 80,p. verge Case (see 162). Perianal 76,p. Case abscess (see 152). Perianal haematoma 74,p. Case (see 148). Strangulated haemorrhoids 73,p. Case (see 147). Fissure inano. Apart froma right-sided repair 5yearsbefore,he A fissure inano. An agonizing anal verge • a lubricant laxative and prescribing hot baths. Relaxation aided by relieving pain with an ointment, giving An early fissure small may spontaneously. heal This is How isthisconditiontreated? bowel. large This typicallyis encountered inCrohn’s the of disease would yoususpect? anal verge,whatunderlyingpathology If multiplefissures were seenatthe ination would, inany pretty be case, well impossible. sphincter is inmarked spasmcondition inthis and exam - The area is exquisitely tender. Moreover,the external anal this stage? not performarectal examination at Why didthe(kindhearted)surgeon 12o’clock inthe occur position. Occasionally,coccyx. female, inthe it especially may 6o’clock inthe case, this position, directed towards the fissure. The great majority these fissures of occur, asin is torn the oftag anal epithelium that ‘points’ to the Note associated the sentinel (the skintag also pile) which An (fissure in ano) –atear the at anal verge. What pathologyhasbeenexposed? obvious pathology.

area andwasnotgoing to performarectalexamination. surgeon reassured him thathewasonly going toinspectthe apprehensive,butthe revealed. Thepatientwasvery gently drawnaside,thelesionshowninFig.75.1was position with hiskneesdrawnup.Whenthebuttockswere surgeon thenaskedthepatienttolieinleftlateral there wasnothing to findongeneralexamination.The from awell healed scarfromarightinguinalhernia repair, The surgeonnowproceeded to examinethepatient. Apart Proctalgia fugax –attacks fugax Proctalgia of severe anal pain without 150 usually allows healing to place. take If fail, methods these with injection of to relax sphincter the If that is unsuccessful a‘chemical then sphincterotomy’ trinitrateing or 2%diltiazem (GTN)cream. 0.2%glyceryl of internal the anal sphincter may achieved by be ap ­ply- damaged years before inchildbirth. in parous women sphincter whose may have been risk ofthe incontinence of flatus particularly and faeces, internal sphincterotomy considered, can be but carries Case 75 151

Part 2: cases