Haemorrhoids

Question 1

ESSENCE

Answer 1

Enlarged vascular cushions

Question 2

AETIOLOGY

Risk factors

Answer 2

• Age 45-65
• Constipation - causes chronic straining
• Pregnancy or space occupying lesion
• Obesity
• Increased intra-abdominal pressure (weightlifting or chronic coughing)

Answer 3

*

Question 4

ANATOMY

What are anal cushions

Answer 4

Specialised submucosial tissue that contains connections between arteries and veins, making them very vascular

Supported by smooth muscle and connective tissue

Help control anal incontinence

Question 5

Where are anal cushions located (clock face)

Answer 5

• If patient in lithotomy position (on back legs raised)
  
  • Located at 3, 7 and 11 oclock

Question 6

CLASSIFICATION

Answer 6

• 1st degree
  
  • No prolapse
• 2nd degree
  
  • Prolapse when straining and returning on relaxing
• 3rd degree
  
  • Prolapse when straining, do not return on relaxing but can be pushed back
• 4th degree
  
  • Permanently prolapsed

Question 7

CLINICAL FEATURES

Presentation

Answer 7

• May be asymptomatic
• Often associated with constipation and straining
• Common presentation is painless, bright red bleeding
  
  • Blood not mixed with stool
• Sore/itchy anus
• Feeling lump around or inside anus

Question 8

CLINICAL FEATURES

Examination findings

Answer 8

• External (prolapsed)
  
  • Visible on inspection as swellings covered in mucosa
• Internal
  
  • May be felt on PR exam
  • May appear if patient asked to bear down

Question 9

INVESTIGATION

First choice

Answer 9

Proctoscopy

Question 10

MANAGEMENT

General principles

Answer 10

• Consider differential diagnosis for patients presenting with rectal bleeding
• Consider testing for anaemia
• Topical treatments can be given for symptomatic relief
• Treatment for prevention of constipation
• Non-surgical treatment for haemorrhoids
• Surgical treatment for haemorrhoids

Question 11

MANAGEMENT

Topical treatments for symptomatic relief

Answer 11

• Anusol (contains chemicals to shrink haemorrhoid - astringents)
• Anusol HC (also contains hydrocortisone, used short term)
• Germaloids cream (contains lidocaine, local anaesthetic)
• Proctesedyl ointment (contains cinchocaine and hydrocortisone, short term)

Question 12

MANAGEMENT

Prevention and treatment of constipation

Answer 12

• Increase fibre in diet
• Maintain good fluid intake
• Use laxatives as required
• Consciously avoiding straining when opening bowels

Question 13

MANAGEMENT

Non-surgical treatment for haemorrhoids

Answer 13

• Subber band ligation
• Injection sclerotherapy
• Infra-red coagulation
• Bipolar diathermy

Question 14

What is rubber band ligation

Answer 14

Fitting a tight rubber band around base of haemorrhoid to cut blood supply

Question 15

What is injection sclerotherapy

Answer 15

Injection of phenol oil into the haemorrhoid to cause sclerosis and atrophy

Question 16

What is infra-red coagulation

Answer 16

Infra red light applied to damage blood supply

Question 17

What is bipolar diathermy

Answer 17

Electrical current applied directly to haemorrhoid to destroy it

Question 18

MANAGEMENT

Surgical options

Answer 18

• Haemorrhoid artery ligation
• Haemorrhoidectomy
• Stapled haemorrhoidectomy

Question 19

What is haemorrhoidal artery ligation

Answer 19

Proctoscope to identify bloods vessels that supplies haemorrhoid, suturing to cut it off

Question 20

What is stapled haemorrhoidectomy

Answer 20

Using special device to excise ring of haemorrhoid tissue at same time as adding circle of staples in anal canal, which stay in place long term

Question 21

Key complication

Answer 21

• Thombosis - thrombosed haemorrhoids
  
  • Caused by strangulation at base of haemorrhoid

Question 22

Presentation of thrombosed haemorrhoids

Answer 22

• Can be very painful
• Appear as purplish, very tender, swollen lumps around anus

Question 23

Treatment of thrombosed haemorrhoids

Answer 23

Resolve with time, although can take weeks