Haemorrhoids Flashcards
What are Haemorrhoids?
Disrupted/dilated anal cushions
Prolapses of anal cushions - contain dilated rectal venous plexus/mucosa
Describe the anal cushions
Highly vascular areas of smooth muscle
Contribute to continence along w/ anal sphincter
Found at 3, 7, 11 o’clock (from Lithotomy position)
How do Haemorrhoids arise?
Arise due to a breakdown of Smooth Muscle layer (muscularis mucosae)
How are Haemorrhoids classified?
Internal (above dentate line)
External (below dentate line)
What is the dentate/pectinate line?
Line dividing upper 2/3 and lower 1/3 of anal canal
How can internal haemorrhoids be further classified?
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
What are the Sx of Haemorrhoids?
Rectal bleeding (bright red) Prolapse Mucous discharge Pruritis ani Pain (if piles thrombosed) Feeling a lump
What are the complications of Haemorrhoids?
Anaemia
Thrombosis
Describe Haemorrhoid thrombosis
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
How should a patient with Haemorrhoids be examined?
Abdominal exam
Rectal exam
Proctoscopy/rigid sigmoidoscopy
Colonoscopy/flexi-sigmoidoscopy
What findings may be present on an abdominal exam?
Palpable masses
Enlarged liver
What findings may be present on a rectal examination?
Visualise haemorrhoid
Palpate haemorrhoid on PR
What is proctoscopy/rigid sigmoidoscopy used for?
Visualize piles
Assess for higher lesions
What is colonoscopy/flexi sigmoidoscopy used for?
If Sx suggest a malignant pathology
What are the causes of haemorrhoids?
Idiopathic Chronic constipation/straining Obesity Pregnancy Increasing age Increased intrabdominal pressure
What is the ddx for rectal bleeding?
Diverticular disease Anal fissures UC Crohns Rectal Ca Colonic Ca
What is the significance of the venous drainage of the rectum?
Anastomoses of anal cushions are porto-caval
-in portal HTN may give ano-rectal varices
What are the conservative management options for haemmorhoids?
Increase fluid intake Increase fibre intake Analgesia for discomfort Laxatives Avoid straining
What are the non-conservative management options for haemmorhoids?
Rubber band ligation
Sclerotherapy- not as commonly used
Can both be done as outpatient
What are the key features of sclerotherapy?
5% phenol in almond oil injected above each pile
1st/2nd degree piles
Painless
Repeat injections each mo
What are the key features of banding?
Small rubber band applied to protruding mucosa
Leads to strangulation
1st-3rd degree piles
Must position band ABOVE dentate line
What are the key features of surgery?
This is done if large haemorrhoid which has not responded to outpatient treatment
Haemorrhoid artery band ligation
What is a perianal haematoma?
Thrombosed external pile
Covered by sq epithelium –> PAINFUL
What are the clinical features of a perianal haematoma?
Acute onset w/ sudden pain & lump at anal verge
- tense
- smooth
- dark-blue
- cherry sized
What are the management options for a perianal haematoma?
Conservative
-will either subside or rupture over a few days
-if discharging clotted blood/being resorbed recommend hot baths & reassure
Incision/drainage (acute phase)
