[15] Haemorrhoids Flashcards by Brainscape Admin

What are haemorrhoids?

Abnormal swellings or enlargement of the anal vascular cushions

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What is the purpose of the anal vascular cushions?

They act to assist the anal sphincter in maintaining continence

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How many vascular cushions are there in the anus?

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Where are the vascular cushions in the anus positioned?

3-, 7-, and 11- o’clock position (when looked at with the patient in the lithotomy position)

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What happens when the vascular cushions in the anus become abnormally enlarged?

They can cause symptoms and become pathological, termed haemorrhoids

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What is the prevalence of haemorrhoids?

It varies, mainly due to the wrong attribution of anorectal symptoms

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When is the peak prevalence of haemorrhoids?

45-65 years

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What are haemorrhoids classified according too?

Their size

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What is a 1st degree haemorrhoid?

One that remains in the rectum

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What is a 2nd degree haemorrhoid?

One that prolapses through the anus on defecation, but spontaneously reduces

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What is a 3rd degree haemorrhoid?

One that prolapses through the anus on defecation, but requires digital reduction

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What is a 4th degree haemorrhoid?

One that remains persistently prolapsed

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What is the cause of most haemorrhoids?

Most are idiopathic

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What are the main risk factors for the development of haemorrhoids?

Excessive straining
Increasing age
Raised intra-abdominal pressure

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What can cause excessive staining?

Chronic constipation

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What can cause raised intra-abdominal pressure leading to haemorrhoids?

Pregnancy
Chronic cough
Ascites

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What are the less common risk factors for haemorrhoids?

Pelvic or abdominal masses
Family history
Cardiac failure
Portal hypertension

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How do haemorrhoids typically present?

Painless bright red bleeding
Pruritis
Prolapse
Soiling

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Describe the features of the blood in haemorrhoids

It commonly occurs after defecation, and is often seen either on the paper or covering the pan
Blood is seen on the surface of the stool, not mixed in

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What causes pruritis in haemorrhoids?

Chronic mucus discharge and irritation

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How does prolapse in haemorrhoids present?

As rectal fullness or an anal lump

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What causes soiling in haemorrhoids?

Impaired continence or mucus discharge

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What can happen to large prolapsed haemorrhoids?

They can thrombose

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How does a thrombosed haemorrhoid present?

It is incredibly painful, and these patients frequently present acutely as an emergency patient

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What will be found on examination with haemorrhoids?

Examination will usually be normal unless the haemorrhoids have prolapsed

How will a thrombosed prolapsed haemorrhoid present?

As a purple/blue, oedematous, tense, and tender palpable mass

What is it important to exclude when a patient presents with suspected haemorrhoids?

Other causes of rectal bleeding, such as malignancy, inflammatory bowel disease, or diverticular disease

What other perianal differentials should be considered in a patient with suspected haemorrhoids?

``` Fissure-in-ano Perianal haematoma Perianal abscess Skin tag Prolapsing rectal polyps ```

What investigations may be done in haemorrhoids?

Proctoscopy FBC Flexible sigmoidoscopy or colonoscopy

What is the purpose of proctoscopy in haemorrhoids?

To confirm the diagnosis

Why may a FBC be required in haemorrhoids?

If there is any significant/prolonged bleeding, or signs of anaemia

What is the purpose of a flexible sigmoidoscopy or colonoscopy in haemorrhoids?

May be considered to exclude malignancy or polyps

What % of haemorrhoids can be managed conservatively?

95%

What is involved in the conservative management of haemorrhoids?

Lifestyle changes Laxatives if necessary Topical analgesia

What lifestyle advice should be given in haemorrhoids?

Increasing daily fibre and fluid intake

Give an example of a topical analgesia used in haemorrhoids?

Lignocaine gel

Why should oral opioids be avoided in haemorrhoids?

As they can compound any constipation

How can symptomatic 1st degree and 2nd degree haemorrhoids be treated?

Rubber-band ligation

What happens in rubber band ligation?

The haemorrhoid is drawn into the end of a suction gun, and rubber band is placed over the neck of the haemorrhoid

What are the main complications of rubber band ligation?

Recurrence Pain Bleeding

When will rubber band ligation cause pain?

If the band is mistakenly placed below the dentate line

When does bleeding normally occur following rubber-band ligation?

Approximately 10 days

Why does bleeding occur approximately 10 days after rubber band ligation?

Because this is when the band and haemorrhoid drops off

What can rarely happen with the bleeding following a rubber band ligation of haemorrhoids?

It can be severe, and require surgical intervention

What are the other options for non-surgical intervention for haemorrhoids?

Infrared coagulation/photocoagulation Bipolar diathermy Direct-current electrotherapy Haemorrhoid artery ligation

When will rubber band ligation cause pain?

If the band is mistakenly placed below the dentate line

When does bleeding normally occur following rubber-band ligation?

Approximately 10 days

Why does bleeding occur approximately 10 days after rubber band ligation?

Because this is when the band and haemorrhoid drops off

What can rarely happen with the bleeding following a rubber band ligation of haemorrhoids?

It can be severe, and require surgical intervention

What to patients often want in terms of management of their haemorrhoids?

Just want reassurance that bleeding is not caused by malignancy, and are not too troubled by their symptoms. Reassurance alone may therefore by sufficient management for many people

What is good about haemorrhoidal artery ligation?

It has an effectiveness level similar to that of surgical interventions

Why may a patient choose rubber-band ligation over haemorrhoidal artery ligation?

HAL is more painful, therefore patients may prefer a course of RBL to the more invasive HBL

What % of patients with haemorrhoids will eventually need a haemorrhoidectomy?

When is a haemorrhoidectomy indicated?

If patients are symptomatic and not responding to conservative therapies, yet are unsuitable for banding/injection

What class of haemorrhoids typically are more likely to need haemorrhoidectomies?

3rd and 4th degree

What are the techniques used in haemorrhoidectomy?

Stapled haemorrhoidectomy | Milligan Morgan haemorrhoidectomy

What are the main complications of haemorrhoidectomies?

``` Bleeding Infection Constipation Stricture Anal fissures Faecal incontinence ```

Is a haemorrhoidectomy a painful procedure?

Yes, notoriously so

What are the complications of haemorrhoids?

Ulceration due to thrombosis Skin tags Ischaemia, thrombosis, or gangrene Perianal sepsis

When may ischaemia, thrombosis, or gangrene occur in haemorrhoids?

4th degree internal haemorrhoids