Haemorrhoids

Question 1

Define haemorrhoids

Answer 1

Anal vascular cushions become enlarged & engorged w/ a tendency to protrude, bleed or prolapse in the anal canal

Question 2

Classification of haemorrhoids

2

Answer 2

Internal - arise from the superior haemorrhoids plexus & lie ABOVE the dentate line

External - lie BELOW the dentate line

Question 3

Degrees of haemorrhoids

4

Answer 3

1st degree - do NOT prolapse

2nd degree - prolapse w/ defecation but REDUCE SPONTANEOUSLY

3rd degree - prolapse & require MANUAL REDUCTION

4th degree - prolapse CANNOT be reduced

Question 4

Define dentate line

Answer 4

Line that divides upper 2/3 & lower 1/3 of the anal canal & represents the hindgut-proctodeum junction

Question 5

Aetiology of haemorrhoids

2

Answer 5

Exact cause disputed

Caused by disorganisation of fibromuscular stroma of anal cushions

Question 6

Risk factors for haemorrhoids

5

Answer 6

Constipation
Prolonged straining 
Derangement of internal anal sphincter 
Pregnancy
Portal hypertension

Question 7

Epidemiology of haemorrhoids

prevalence, age

Answer 7

COMMON

Peak age 45-64 yrs

Question 8

Presenting symptoms of haemorrhoids

general + 6

Answer 8

Usually ASYMPTOMATIC

Bleeding - bright red on paper & drips after stool (NOT mixed)
Absence of alarm symptoms - weight loss anaemia, change in bowel habit, passage of clotted/dark blood, mucus mixed
Itching
Anal lumps
Prolapsing tissue

Thrombosed external haemorrhoids can be VERY PAINFUL

Question 9

Signs of haemorrhoids on physical examination

3

Answer 9

1st or 2nd degree haemorrhoids NOT usually visible on external inspection
Internal haemorrhoid NOT normally palpable on DRE unless throbbed
Haemorrhoids usually visible on proctoscopy

Question 10

Differential diagnoses of haemorrhoids

5

Answer 10

Anal tags
Anal fissures
Rectal prolapse
Polyps
Tumours

Question 11

Investigations for haemorrhoids

3

Answer 11

DRE
Proctoscopy
Rigid or flexible sigmoidoscopy
IMPORTANT to exclude other source of bleeding

Question 12

Management of haemorrhoids

4

Answer 12

Conservative
Injection sclerotherapy
Banding
Surgery

Question 13

Management of haemorrhoids - conservative

4

Answer 13

High-fibre diet
Increased fluid intake
Bulk laxatives
Topical creams (e.g. LA)

Question 14

Management of haemorrhoids - injection sclerotherapy

Answer 14

Induces fibrosis of dilated veins

Question 15

Management of haemorrhoids - banding

3

Answer 15

Barron’s bands applied proximal to haemorrhoids
Haemorrhoid will then fall off after a few days
Higher cure rate but may be more painful than injection sclerotherapy

Question 16

Management of haemorrhoids - surgery

4

Answer 16

Reserved for symptomatic 3rd/4th degree haemorrhoids
Milligan-Morgan haemorrhoidectomy - excision of 3 haemorrhoids cushions
Staples haemorrhoidectomy is alternative method
Post-op patient should be given laxatives to avoid constipation

Question 17

Complications of haemorrhoids - general

4

Answer 17

Bleeding
Prolapse
Thrombosis
Gangrene

Question 18

Complications of haemorrhoids - injection sclerotherapy

5

Answer 18

Prostatitis
Perineal sepsis
Impotence 
Retroperitoneal sepsis
Hepatic abscess

Question 19

Complications of haemorrhoids - haemorrhoidectomy

4

Answer 19

Pain
Bleeding
Incontinence
Anal stricture

Question 20

Prognosis of haemorrhoids

3

Answer 20

Often CHRONIC
High rate of recurrence
Surgery can provide long term relief