Anal and Rectal Lesions - Haemorrhoids

Question 1

What are haemorrhoids?

Answer 1

Enlarged anal vascular cushions.

Question 2

Risk Factors of haemorrhoids (5).

Answer 2

1. Pregnancy (constipation, pressure from the baby and hormonal relaxation of connective tissues).
2. Obesity.
3. Increasing Age.
4. Increased Intra-abdominal pressure e.g. weightlifting, chronic coughing.
5. Portal HTN secondary to Cirrhosis (increased pressure at the rectal porto-systemic anastomosis).

Question 3

Anatomy of the anal cushions.

Answer 3

Specialised submucosal tissue that contain connections between the arteries and veins making them very vascular - they are supported by smoohh muscle and connective tissue.

Question 4

Function of the anal cushions.

Answer 4

Control anal continence, along with the internal and external sphincters.

Question 5

Blood supply of the anal cushions.

Answer 5

Rectal arteries.

Question 6

Positioning of the anal cushions.

Answer 6

Usual Locations : 3, 7 and 11 O’Clock.
12 O’ Clock = Genitals and 6 O’Clock = Back.
Describe it in the lithotomy position (on back with legs raised).

Question 7

Classification of haemorrhoids (4).

Answer 7

1st Degree - No Prolapse : Conservative + Topical Corticosteroids.
2nd Degree - Prolapse when straining and return on relaxing : Rubber Band Ligation (or Non-Surgical Management).
3rd Degree - Prolapse when straining, do not return on relaxing but can be pushed back : Rubber Band Ligation (or Non-Surgical Management).
4th Degree - Prolapse permanently - Haemorrhoidectomy.

Question 8

Clinical Features of haemorrhoids (5).

Answer 8

1. Asymptomatic.
2. Association : Constipation and Straining.
3. Painless, bright red bleeding - typically on the toilet tissue seen after opening bowels; blood is not mixed with the stool.
4. Sore/Itchy Anus.
5. Lump Sensation Around/Inside Anus.

Question 9

Investigations of haemorrhoids (2).

Answer 9

1. DRE - External (Inspection) and Internal (Palpation).
2. Proctoscopy - Proper Visualisation - proctoscope into anal cavity to visualise mucosa.
3. Bloods - Anaemia (Prolonged Bleeding).

Question 10

Differential diagnoses of rectal bleeding (4).

Answer 10

1. Anal fissures.
2. Diverticulosis.
3. Inflammatory Bowel Disease.
4. Colorectal Cancer.

Question 11

Symptomatic Management of haemorrhoids (4).

Answer 11

Aim : Reduce Swelling and Symptomatic Relief.

1. Anusol : Shrink Haemorrhoids (astringents).
2. Anusol HC : with Hydrocortisone (short-term only).
3. Germaloids : with Lidocaine (local anaesthetic).
4. Proctosedyl Ointment : with Cinchocaine and Hydrocortisone - short-term only).

Question 12

Preventative Management of constipation (4).

Answer 12

1. High-fibre diet.
2. Good fluid-intake.
3. Laxatives.
4. Avoiding straining when opening bowels.

Question 13

Non-surgical Management of haemorrhoids (4).

Answer 13

1. Rubber Band Ligation (fitting a tight rubber band around the base of the haemorrhoid to cut off the blood supply).
2. Injection Sclerotherapy (phenol oil injection into haemorrhoid to cause sclerosis and atrophy).
3. Infra-red coagulation (infra-red light applied to damage the blood supply).
4. Bipolar diathermy (electrical current applied directly to the haemorrhoid to destroy it).

Question 14

Surgical Management of haemorrhoids (3).

Answer 14

1. Haemorrhoidal Artery Ligation (Proctoscope to identify vessel that supplies the haemorrhoids and suturing it off to cut blood supply).
2. Haemorrhoidectomy (excision of haemorrhoid but removal of anal cushion can result in faecal incontinence).
3. Stapled haemorrhoidectomy (special device to excise a ring of haemorrhoid tissue and add a circle of staples in the anal canal to remain long-term).

Question 15

Aetiology of Thrombosed Haemorrhoids.

Answer 15

Strangulation at the base of the haemorrhoid, resulting in thrombosis (a clot) in the haemorrhoid.

Question 16

Clinical Features of Thrombosed Haemorrhoids.

Answer 16

Purplish tender painful swollen lumps around anus.

Question 17

Management of Thrombosed Haemorrhoids.

Answer 17

1. Resolves with time (10 days) : stool softeners, ice packs and analgesia.
2. Within 72 Hours : Surgical Admission and Management Considered.

Question 18

Types of Haemorrhoids (2).

Answer 18

1. External - originate below dentate line and prone to thrombosis.
2. Internal - originate above dentate line and do not generally cause pain.