Chapter 48: Anus- Hemorrhoids Flashcards
What are they?
Engorgement of the venous plexuses of the rectum, anus, or both; with protrusion of the mucosa, anal margin, or both
Why do we have “healthy” hemorrhoidal tissue?
It is thought to be involved with fluid/air continence
What are the signs/symptoms?
- Anal mass/prolapse
- bleeding
- itching
- pain
Which type, internal or external, is painful?
External, below the dentate line
If a patient has excruciating anal pain and history of hemorrhoids,what is the likely diagnosis?
Thrombosed external hemorrhoid (treat by excision)
What are the causes of hemorrhoids?
- Constipation/straining
- portal hypertension
- pregnancy
What is an internal hemorrhoid?
Hemorrhoid above the (proximal) dentate line
What is an external hemorrhoid?
Hemorrhoid below the dentate line
What are the three “hemorrhoid quadrants”?
- Left lateral
- Right posterior
- Right anterior
First-degree hemorrhoid
Hemorrhoid that does not prolapse
Second-degree hemorrhoid
Prolapses with defecation, but returns on its own
Third-degree hemorrhoid
Prolapses with defecation or any type of Valsalva maneuver and requires active manual reduction (eat fiber!)
Fourth-degree hemorrhoid
Prolapsed hemorrhoid that cannot be reduced
What is the treatment?
- 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
What is a “closed” versus an “open” hemorrhoidectomy?
- Closed (Ferguson) “closes” the mucosa with sutures after hemorrhoid tissue removal
- Open (Milligan–Morgan) leaves mucosa “open”
What are the dreaded complications of hemorrhoidectomy?
- 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
What condition is a contraindication for hemorrhoidectomy?
Crohn’s disease
Classically, what must be ruled out with lower GI bleeding believed to be caused by hemorrhoids?
Colon cancer (colonoscopy)
56-year-old woman with hemorrhoids that prolapse with defecation but then retract by themselves
Second-degree internal hemorrhoids
34-year-old woman with hemorrhoids that prolapse after defecation and that she has to “push back in”
Third-degree internal hemorrhoids
56-year-old woman with hemorrhoids that are “stuck out” after a bowel movement
Fourth-degree internal hemorrhoid
22-year-old female with bright red blood from her rectum with history of extremely painful bowel movements
Anal fissure
