[15] Haemorrhoids Flashcards
What are haemorrhoids?
Abnormal swellings or enlargement of the anal vascular cushions
What is the purpose of the anal vascular cushions?
They act to assist the anal sphincter in maintaining continence
How many vascular cushions are there in the anus?
3
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)
What happens when the vascular cushions in the anus become abnormally enlarged?
They can cause symptoms and become pathological, termed haemorrhoids
What is the prevalence of haemorrhoids?
It varies, mainly due to the wrong attribution of anorectal symptoms
When is the peak prevalence of haemorrhoids?
45-65 years
What are haemorrhoids classified according too?
Their size
What is a 1st degree haemorrhoid?
One that remains in the rectum
What is a 2nd degree haemorrhoid?
One that prolapses through the anus on defecation, but spontaneously reduces
What is a 3rd degree haemorrhoid?
One that prolapses through the anus on defecation, but requires digital reduction
What is a 4th degree haemorrhoid?
One that remains persistently prolapsed
What is the cause of most haemorrhoids?
Most are idiopathic
What are the main risk factors for the development of haemorrhoids?
Excessive straining
Increasing age
Raised intra-abdominal pressure
What can cause excessive staining?
Chronic constipation
What can cause raised intra-abdominal pressure leading to haemorrhoids?
Pregnancy
Chronic cough
Ascites
What are the less common risk factors for haemorrhoids?
Pelvic or abdominal masses
Family history
Cardiac failure
Portal hypertension
How do haemorrhoids typically present?
Painless bright red bleeding
Pruritis
Prolapse
Soiling
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
What causes pruritis in haemorrhoids?
Chronic mucus discharge and irritation
How does prolapse in haemorrhoids present?
As rectal fullness or an anal lump
What causes soiling in haemorrhoids?
Impaired continence or mucus discharge
What can happen to large prolapsed haemorrhoids?
They can thrombose
How does a thrombosed haemorrhoid present?
It is incredibly painful, and these patients frequently present acutely as an emergency patient
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?
5%
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
