Haemorrhoids

Question 1

How can you describe the location of pathology at the anus?

Answer 1

Clock face:

• 12 o’clock is towards the genitals
• 6 o’clock is towards the back

Question 2

Describe the types and classification of haemorrhoids

Answer 2

Types: internal vs external

• Internal piles originate above the dentate line, generally not painful
• External piles originate below the dentate line, may be painful/prone to thrombosis

Classification:

• 1st degree: no prolapse
• 2nd degree: prolapse when straining, reduce spontaneously
• 3rd degree: can be manually reduced
• 4th degree: cannot be reduced

Question 3

What is the most common presenting feature of haemorrhoids?

Answer 3

• Painless, bright red PR bleeding (typically on the toilet tissue or seen in the bowl after opening the bowels - NOT mixed with stool)
• Pruritus

Question 4

Which tool may be used to visualise internal hameorrhoids?

Answer 4

Proctoscope

Question 5

What other differential diagnoses are important to consider in a case of suspected haemorrhoids?

Answer 5

• Anal fissure
• IBD (fistula)
• Colorectal cancer

Question 6

Describe the conservative, medical, interventional and surgical management options to treat haemorrhoids

Answer 6

Conservative:
- Prevention/treatment of constipation (increase fibre + fluid intake)

Medical:

• Bulk-forming laxatives
• Topical local anaesthetic/steroids

Interventional/surgical:

• Rubber band ligation
• Haemorrhoidectomy
• Haemorrhoidal artery ligation

Question 7

What is a thrombosed haemorrhoid?

Answer 7

Formation of a clot within the haemorrhoid

Question 8

Describe the clinical features of a thrombosed haemorrhoid

Answer 8

Purplish, swollen, very tender lump around the anus

Question 9

Describe the management of a thrombosed haemorrhoid

Answer 9

It will resolve spontaneously, although this may take several weeks (however NICE recommends referral to hospital if presenting within 72 hours of onset, as these patients may benefit form surgical intervention)