Haemorrhoids

Question 1

What are Haemorrhoids?

Answer 1

Disrupted/dilated anal cushions

Prolapses of anal cushions - contain dilated rectal venous plexus/mucosa

Question 2

Describe the anal cushions

Answer 2

Highly vascular areas of smooth muscle
Contribute to continence along w/ anal sphincter
Found at 3, 7, 11 o’clock (from Lithotomy position)

Question 3

How do Haemorrhoids arise?

Answer 3

Arise due to a breakdown of Smooth Muscle layer (muscularis mucosae)

Question 4

How are Haemorrhoids classified?

Answer 4

Internal (above dentate line)

External (below dentate line)

Question 5

What is the dentate/pectinate line?

Answer 5

Line dividing upper 2/3 and lower 1/3 of anal canal

Question 6

How can internal haemorrhoids be further classified?

Answer 6

Grade 1 - confined to anal canal, bleed, no prolapse
Grade 2 - prolapse on defecation, reduce spontaneously
Grade 3 - prolapse outside anal margin on defecation, manually reducible
Grade 4 - prolapsed outside anal margin at all times

Question 7

What are the Sx of Haemorrhoids?

Answer 7

Rectal bleeding (bright red)
Prolapse
Mucous discharge
Pruritis ani
Pain (if piles thrombosed)
Feeling a lump

Question 8

What are the complications of Haemorrhoids?

Answer 8

Anaemia

Thrombosis

Question 9

Describe Haemorrhoid thrombosis

Answer 9

Strangulation of haemorrhoid resulting in thrombus formation
Leads to acute pain
Purple, tender lump around anus
Cannot do PR as toon painful

Tx with cold compress, analgesia and rest

Question 10

How should a patient with Haemorrhoids be examined?

Answer 10

Abdominal exam
Rectal exam
Proctoscopy/rigid sigmoidoscopy
Colonoscopy/flexi-sigmoidoscopy

Question 11

What findings may be present on an abdominal exam?

Answer 11

Palpable masses

Enlarged liver

Question 12

What findings may be present on a rectal examination?

Answer 12

Visualise haemorrhoid

Palpate haemorrhoid on PR

Question 13

What is proctoscopy/rigid sigmoidoscopy used for?

Answer 13

Visualize piles

Assess for higher lesions

Question 14

What is colonoscopy/flexi sigmoidoscopy used for?

Answer 14

If Sx suggest a malignant pathology

Question 15

What are the causes of haemorrhoids?

Answer 15

Idiopathic
Chronic constipation/straining
Obesity
Pregnancy
Increasing age
Increased intrabdominal pressure

Question 16

What is the ddx for rectal bleeding?

Answer 16

Diverticular disease
Anal fissures
UC
Crohns
Rectal Ca 
Colonic Ca

Question 17

What is the significance of the venous drainage of the rectum?

Answer 17

Anastomoses of anal cushions are porto-caval

-in portal HTN may give ano-rectal varices

Question 18

What are the conservative management options for haemmorhoids?

Answer 18

Increase fluid intake
Increase fibre intake
Analgesia for discomfort
Laxatives
Avoid straining

Question 19

What are the non-conservative management options for haemmorhoids?

Answer 19

Rubber band ligation
Sclerotherapy- not as commonly used

Can both be done as outpatient

Question 20

What are the key features of sclerotherapy?

Answer 20

5% phenol in almond oil injected above each pile
1st/2nd degree piles
Painless
Repeat injections each mo

Question 21

What are the key features of banding?

Answer 21

Small rubber band applied to protruding mucosa
Leads to strangulation
1st-3rd degree piles
Must position band ABOVE dentate line

Question 22

What are the key features of surgery?

Answer 22

This is done if large haemorrhoid which has not responded to outpatient treatment

Haemorrhoid artery band ligation

Question 23

What is a perianal haematoma?

Answer 23

Thrombosed external pile

Covered by sq epithelium –> PAINFUL

Question 24

What are the clinical features of a perianal haematoma?

Answer 24

Acute onset w/ sudden pain & lump at anal verge

• tense
• smooth
• dark-blue
• cherry sized

Question 25

What are the management options for a perianal haematoma?

Answer 25

Conservative
-will either subside or rupture over a few days
-if discharging clotted blood/being resorbed recommend hot baths & reassure
Incision/drainage (acute phase)