Chapter 48: Anus- Hemorrhoids

Question 1

What are they?

Answer 1

Engorgement of the venous plexuses of the rectum, anus, or both; with protrusion of the mucosa, anal margin, or both

Question 2

Why do we have “healthy” hemorrhoidal tissue?

Answer 2

It is thought to be involved with fluid/air continence

Question 3

What are the signs/symptoms?

Answer 3

• Anal mass/prolapse
• bleeding
• itching
• pain

Question 4

Which type, internal or external, is painful?

Answer 4

External, below the dentate line

Question 5

If a patient has excruciating anal pain and history of hemorrhoids,what is the likely diagnosis?

Answer 5

Thrombosed external hemorrhoid (treat by excision)

Question 6

What are the causes of hemorrhoids?

Answer 6

1. Constipation/straining
2. portal hypertension
3. pregnancy

Question 7

What is an internal hemorrhoid?

Answer 7

Hemorrhoid above the (proximal) dentate line

Question 8

What is an external hemorrhoid?

Answer 8

Hemorrhoid below the dentate line

Question 9

What are the three “hemorrhoid quadrants”?

Answer 9

1. Left lateral
2. Right posterior
3. Right anterior

Question 10

First-degree hemorrhoid

Answer 10

Hemorrhoid that does not prolapse

Question 11

Second-degree hemorrhoid

Answer 11

Prolapses with defecation, but returns on its own

Question 12

Third-degree hemorrhoid

Answer 12

Prolapses with defecation or any type of Valsalva maneuver and requires active manual reduction (eat fiber!)

Question 13

Fourth-degree hemorrhoid

Answer 13

Prolapsed hemorrhoid that cannot be reduced

Question 14

What is the treatment?

Answer 14

• High-fiber diet
• anal hygiene
• topical steroids
• sitz baths
• Rubber band ligation
  
  • in most cases anesthetic is not necessary for internal hemorrhoids
• Surgical resection for large refractory hemorrhoids,
• infrared coagulation
• harmonic scalpel

Question 15

What is a “closed” versus an “open” hemorrhoidectomy?

Answer 15

• Closed (Ferguson) “closes” the mucosa with sutures after hemorrhoid tissue removal
• Open (Milligan–Morgan) leaves mucosa “open”

Question 16

What are the dreaded complications of hemorrhoidectomy?

Answer 16

• Exsanguination
  
  • (bleeding may pool proximally in lumen of colon without any signs of external bleeding)
• Pelvic infection
  
  • (may be extensive and potentially fatal)
• Incontinence
  
  • (injury to sphincter complex)
• Anal stricture

Question 17

What condition is a contraindication for hemorrhoidectomy?

Answer 17

Crohn’s disease

Question 18

Classically, what must be ruled out with lower GI bleeding believed to be caused by hemorrhoids?

Answer 18

Colon cancer (colonoscopy)

Question 19

56-year-old woman with hemorrhoids that prolapse with defecation but then retract by themselves

Answer 19

Second-degree internal hemorrhoids

Question 20

34-year-old woman with hemorrhoids that prolapse after defecation and that she has to “push back in”

Answer 20

Third-degree internal hemorrhoids

Question 21

56-year-old woman with hemorrhoids that are “stuck out” after a bowel movement

Answer 21

Fourth-degree internal hemorrhoid

Question 22

22-year-old female with bright red blood from her rectum with history of extremely painful bowel movements

Answer 22

Anal fissure