General: Haemorrhoids

Question 1

Describe the pathophysiology of haemorrhoids

Answer 1

Abnormal swelling or enlargement of the anal vascular cushions

3 anal vascular cushions act to assist the anal sphincter in maintaining continence

Question 2

What are the risk factors for haemorrhoids?

Answer 2

Excessive straining (constipation)

Increasing age

Raised intra-abdo pressure

Pelvic/abdo masses

FH

Cardiac failure

Portal hypertension

Question 3

How can haemorrhoids be classified?

Answer 3

1 = remain in rectum

2 = prolapse but spontaneously reduce

3 = prolapse but require digital reduction

4 = persistently prolapsed

Question 4

How do haemorrhoids present?

Answer 4

Painless bright red bleeding commonly after defecation

Blood is on the surface of the stool, not mixed

Pruritus (due to chronic mucus discharge and irritation)

Prolapse

Soiling (due to impaired continence or mucus discharge)

Question 5

What are the investigations for haemorrhoids?

Answer 5

Visual exam

Proctoscopy

Flexible sigmoidoscopy = exclude malignancy

Question 6

How should haemorrhoids be managed?

Answer 6

95% managed conservatively

Lifestyle = increasing daily fibre and fluid intake to avoid constipation, prescribing any laxatives if necessary

Topical analgesia = lidocaine gel

Rubber-band ligation = Symptomatic 1st degree and 2nd degree haemorrhoids

Haemorrhoidal artery ligation (HAL)

Haemorrhoidectomy = GA, cut out

Question 7

What are the possible complications of haemorrhoids?

Answer 7

Ulceration due to thrombosis

Skin tags

Ischaemia, thrombosis, or gangrene in 4th degree internal haemorrhoids.

Perianal sepsis