Haemorrhoids

Question 1

What are anal cushions and how are they related to haemorrhoids?

Answer 1

Specialised submucosal tissue containing connections between arteries and veins and work with internal and external anal sphincter to control continence

Haemorrhoids= enlarged anal vascular cushions

Question 2

How are haemorrhoids classified?

Answer 2

Dependent on size and whether they prolapse

1st degree= no prolapse
2nd degree= prolapse with straining but return on relax
3rd degree= prolapse when straining and do not return when relax but can be pushed back in
4th degree= permenantly prolapsed and cannot be pushed back in

Question 3

What are risk factors for developing haemorrhoids?

Answer 3

Constipation + straining
Pregnancy= pressure from baby and hormones which relax connective tissue
Obesity
Increased intra-abdominal pressure = weight-lifting or chronic coughing

Question 4

How might someone with haemorrhoids present?

Answer 4

Painless bright red bleeding I.e. seen when wiping on seen in pan (NOT mixed with stool)

Sore/itchy anus
Lump in/around anus

Can be asymptomatic

Question 5

What would you expect to see on PR examination if patient has internal haemorrhoids?

What is required to properly visualise the haemorrhoids?

Answer 5

Can be felt= commonly positioned at 3,7 and 11 o’clock (location of anal cushions)

Can prolapse when patient asked to bear down on finger

Proctoscopy= required for proper visualisation and inspection

Question 6

What are the possible differentials for someone with symptoms suggesting haemorrhoids?

Answer 6

Anal fissure
Diverticulosis
IBD
Colorectal cancer

Question 7

What are the non-surgical treatment options for haemorrhoids?

Answer 7

Topical to reduce the symptoms:

• Anusol= shrinks haemorrhoids
• Germoloids= contains lidocaine so can be used as LA
• Proctosedyl= contains HC so can only be used short term

Treat constipation

Rubber band ligation

Injection scleropathy

Infra-red coagulation= damages blood supply

Bipolar diathermy= electrical current to destroy

Question 8

What are the 3 main surgical approaches to treating haemorrhoids?

Answer 8

Haemorrhoidal artery ligation

Haemorrhoidectomy

Staple haemorrhoidectomy

Question 9

What is a possible complication which can occur with haemorrhoids? How do they differ from normal haemorrhoids?

Answer 9

Thrombosis haemorrhoids= where haemorrhoids becomes strangulated at base and a thrombosis forms in the haemorrhoid

Characteristics= purple, very tender, swollen
I.e. PR exam not possible

NOTE: resolve over time

Question 10

What are the 2 classifications of haemorrhoids?
What are the differences between these 2 types of haemorrhoid?
What anatomical landmark differentiates between them?

Answer 10

External

• below dentate line
• can be seen on examination i.e. swellings from anus
• itchy and painful due to being covered in squamous epithlium innervated by pain fibres

Internal

• can be felt on PR examination
• columnar epithelium
• not usually painful unless they become strangulated
• graded 1-4 depending on degree of prolapse and whether they are reducible

Divided by dentate line= seperates the upper and lower anal canal

Question 11

Why are external haemorrhoids painful and internal haemorrhoids not painful?

Answer 11

External
-lined with squamous epithelium (anoderm) which is innervated by pain fibres meaning they are more likely to be irritated and become painful

Internal
-not innervated in the same way so not usually sensitive to touch/temperature etc
I.e. will only become painful if they become strangulated