haemorrhoids Flashcards
def haemorrhoids
anal vascular cushions that contribute to anal closure become enlarged and engorged, tendency to protrude, bleed or prolapse into the anal canal
aetiology haemorrhoids
disorganisation of fibromuscular supporting stroma of the anal cushions
bowel habit may be normal
RF haemorrhoids
constipation
prolongued straining
derangement of the internal anal sphincter
pregnancy
portal hypertension
pelvic tumour - congestion
path haemorrhoids
excessive straining = engorgement of the cushions
shearing by hard stools = disruption of tissue organisation, hypertrophy and fragmentation of muscle and elastin fibres and downward displacement of the anal cushions, raised resting anal pressures and bleeding from presinusoidal arterioles
cushions protrude through tight anus - become more congested, hypertrophy again to protrude more readily
- protrusions may strangulate
classification of haemorrhoids
classified as internal or external
- internal form the superior haemorrhoidal plexus, lie above dentate line
- external - below dentate line from inferior haemorrhoidal plexus
- combination of types possible
classified by degree of prolapse
- 1st degree - no prolapse
- 2nd - prolapse with defecation, reduce spontaneously
- 3rd - prolapse and manual reduction
- 4th - prolapse, cannot be reduced
epi haemorrhoids
common 4-5%
45-65yrs
sx haemorrhoids
asymptomatic
bleeding - bright red on toilet paper, or dripping, on stool NOT mixed in
absent alarm symptoms - weight loss, anaemia, change in bowel habit, passage of clotted/dark blood in stool, tenesmus
itching
mucus discharge
anal lumps
prolapsing tissue
no sensory fibres above dentate line (squamomucosal junction) = painless unless:
external haemorrhoids that have become thrombosed can cause severe pain, gripped by anal sphincter = blocked venous return
signs haemorrhoids
severe anaemia
PR exam
- prolapsing piles are obvious
- internal haemorrhoids not palpable
- 1st and 2nd degree haemorrhoids not seen from inspection
uncomplicated only seen on proctoscopy - red granular mucosal swellings bulging into view on straining and withdrawal of proctoscope at 3, 7, and 11 oclock
ddx- anal tags, anal fissure, rectal prolapse, polyps or tumour
ix haemorrhoids
rigid or flexible sigmoidoscopy - exclude rectal source of bleeding, haemorrhoids are common and may coexist with colorectal tumours
abdo exam to rule out other diseases
conservative mx haemorrhoids
high fibre diet
increased fluid intake
exercise
bulk laxative
topical cream - contain mild astringents and LA (if corticosteroids only short-term use)
local therapy haemorrhoids
1st/2nd degree
injection sclerotherapy - 2mL 5% phenol in almond oil injected above dentate line (no sensory fibres) into submucosa above a haemorrhoid = inducing inflamm = fibrosis = mucosal fixation
banding
- Barron’s bands - applied prox to haemorrhoid incorporating tissue that falls away after 2-3 days
- leaves small ulcer to heal by secondary intention
- higher cure rates, but more painful
infrared coag
- applied to localised areas of piles
- coagulating vessels and tethering mucosa to subcut tissue
- successful as banding, potentially less painful
bipolar diathermy and direct current electrotherapy
- coagulation and fibrosis after local heat
- success similar to infrared, complication low
sx mx haemorrhoids
symptomatic 3/4th degree
Milligan-Morgan open haemorrhoidectomy - excision of 3 haemorrhoidal cushions, incisions separated by adequate skin or mucosal bridges +- ligation of vasculr pedicles, day case, 2wks off work
stapled haemorrhoidectomy involves mucosectomy 2cm prox to dentate line to ‘hitch up’ prolapsing anal lining and disrupt prox blood flow
- less pain and shorter convalescence, quicker return to work
- used when large internal component - higher recurrence and prolapse rate than excisional
post op lactulose - avoid constipation
prolapsed, thrombosed piles mx
analgesia
ice packs
stool softeners
pain resolves in 2-3wks
some advocate early surgery
complication haemorrhoids
bleeding
prolapse
thrombosis
gangrene
