Haemorrhoids Flashcards
What are haemorrhoids?
- Haemorrhoids are disrupted and dilated anal cushions
- The anus is lined by discontinuous masses of spongy vascular tissue – the anal cushions which contribute to anal closure. These become enlarged and engorged with a tendency to protrude, bleed or prolapse in the anal canal
What are the types of haemorrhoids a patient may have?
- Internal: Lie ABOVE the dentate line
- External: Lie BELOW the dentate line
- Combined: found both above and below the dentate line
Dentate line = a line that divides the upper 2/3 and the lower 1/3 of the anal canal.
How are internal haemorrhoids graded?
- 1st Degree - haemorrhoids that do NOT prolapse
- 2nd Degree - prolapse with defecation but reduce spontaneously
- 3rd Degree - prolapse and require manual reduction
- 4th Degree - prolapse that CANNOT be reduced
What causes haemorrhoids?
Exact cause is disputed
- The 3 anal cushions are at 3, 7 and 11 o’clock – where the 3 major arteries that feed the vascular plexuses enter the anal canal. They are attached by smooth muscle and elastic tissue, but are prone to displacement and disruption, either singly or together. This may be due to effects of gravity, increased anal tone, and the effects of straining – this can cause them to become bulky and loose, and protrude to form piles.
- They are vulnerable to trauma, e.g. from hard stools, and bleed from capillaries of underlying lamina propria. As it is from capillaries, the blood is bright red.
- As there are no sensory fibres, piles are not painful unless they thrombose when they protrude and are gripped by the anal sphincter, blocking venous return.
- Caused by disorganisation of the fibromuscular stroma of the anal cushions
What are the risk factors for haemorrhoids?
- Constipation
- Prolonged straining due to either chronic constipation or diarrhoea
- Derangement of the internal anal sphincter
- Increase in intra-abdominal pressure (pregnancy or ascites)
- Portal hypertension
- Presence of space-occupying lesions within the pelvis
Summarise the epidemiology of haemorrhoids
- COMMON
- Peak age: 45-65 yrs
What are the presenting symptoms of haemorrhoids?
Usually ASYMPTOMATIC
1. Bleeding
- Bright red blood that is on the toilet paper and drips into the pan after passage of stool
- Blood will NOT be mixed with the stool
2. ABSENCE of alarm symptoms (weight loss, anaemia, change in bowel habit, passage of clotted or dark blood, mucus mixed with the stool)
3. Other symptoms:
- Itching
- Anal lumps
- Perianal Pain/Discomfort → may be associated with feeling of incomplete evacuation
- Prolapsing tissue
NOTE: external haemorrhoids that have thrombosed can be very PAINFUL
What signs of haemorrhoids can be found on physical examination
- 1st or 2nd degree haemorrhoids are NOT usually visible on external inspection
- Internal haemorrhoids are NOT normally palpable on DRE unless they are thrombosed
- Haemorrhoids are usually visible on proctoscopy
- Anal Pruritus (itch)
- Tender Palpable Perianal Lesion
- Anal Mass
- Differential Diagnosis
- Anal tags
- Anal fissures
- Rectal prolapse
- Polyps
- Tumours
What are some alarm signs of a thrombosed haemorroid?
Thrombosed Haemorrhoids → significant pain and tender lump. Purplish, oedematous, tender subcutaneous perianal mass.
What investigations are used to diagnose/ monitor haemorroids?
- Anoscopic Examination (Proctoscopy/rigid sigmoidoscopy) → 1st line and diagnostic
- Colonoscopy / Flexible Sigmoidoscopy → exclude serious pathology such as IBD or Cancer (presence of symptoms such as altered bowel habit, abdominal pain, weight loss, iron-deficiency anaemia etc.)
- DRE
How are haemorroids managed?
1st line for all patients → Dietary & Lifestyle Modification (Increased fibre intake & Adequate fluids will soften stools)
- Grade I → Topical Corticosteroids (relieves pruritus)
- Grade II + III → Rubber Band Ligation
*Barron’s bands are applied proximal to the haemorrhoids
*The haemorrhoid will then fall off after a few days
- Grade IV → Surgical Haemorrhoidectomy: excision of three haemorrhoidal cushions
What complications may arise from haemorrhoids?
- Bleeding
- Prolapse
- Thrombosis
- Gangrene
Summarise the prognosis for patients with haemorrhoids
- Often CHRONIC
- High rate of recurrence
- Surgery can provide long-term relief
