surgery

• Fissure in ano

  Painful, bright red rectal bleeding - Stool softeners, topical diltiazem or GTN, botulinum toxin, Sphincterotomy
• Haemorroids

  Painless, bright red rectal bleeding occurs following defecation and bleeds onto the toilet paper and into the toilet pan - Stool softeners, avoid straining, surgery
• Fistula in ano

  May initially present with an abscess and then persisting discharge onto the perineum, separate from the anus - Lay open if low, no sphincter involvement or IBD, if complex, high or IBD insert seton and consider other options 
• Peri anal abscess

  Peri anal swelling and surrounding erythema - Incision and drainage, leave the cavity open to heal by secondary intention
• Pruritus ani

  Peri anal itching, occasional mild bleeding (if severe skin damage) - Avoid scented products, use wet wipes rather than tissue, avoidance of scratching, ensure no underlying faecal incontinence
• Criteria for brain stem death testing

  • Deep coma of known aetiology
  • Reversible causes excluded
  • No sedation 
  • Normal electrolytes
• Moro reflex is a primitive reflex tested for in neonates
• Ankle jerk reflex is deep tendon reflex and tests cutaneous innervation, motor supply, and cortical input at the S1 level
• Jaw jerk reflex is a cranial nerve reflex, but is not routinely tested for in suspected brain stem death
• Types of haemorrhoidsExternal

  • originate below the dentate line
  • prone to thrombosis, may be painful

  Internal

  • originate above the dentate line
  • do not generally cause pain

  Grading of internal haemorrhoidsGrade I - Do not prolapse out of the anal canal

  Grade II - Prolapse on defecation but reduce spontaneously

  Grade III - Can be manually reduced

  Grade IV - Cannot be reduced
• A strangulated hernia is a surgical emergency and requires urgent surgical exploration, and further imaging may delay treatment causing further bowel necrosis and risk of perforation. The Lichtenstein surgical technique is most often used for this problem.
• An inguinal hernia is the protrusion of viscera or abdominal contents through the superficial inguinal ring. Inguinal hernias can either enter this ring directly through the deep inguinal ring or indirectly through the posterior wall of the inguinal canal.Hernias should be reducible, otherwise it is referred to as an incarcerated hernia, which are at risk of strangulation. Incarcerated hernias are typically painless.Strangulation is a surgical emergency where the blood supply to the herniated tissue is compromised, leading to ischemia or necrosis.