Haemorrhoids

Question 1

What are Haemorrhoids?

Answer 1

abnormally swollen vascular mucosal cushions in the anal canal.

Question 2

How can haemorrhoids be classified based on location?

Answer 2

Internal: ABOVE dentate line
External: BELOW dentate line

Question 3

What are the 4 degrees of internal haemorrhoids?

Answer 3

1st: DONT prolapse
2nd: prolapse with defecation but reduce spontaneously
3rd: prolapse + require manual reduction
4th: prolapse, CANT be reduced

Question 4

List 6 risk factors for haemorrhoids

Answer 4

AGE (weakening of support structures)
Constipation
Prolonged straining
Heavy lifting
Raised intra-abdominal pressure (Pregnancy, ascites)
Low fibre diet

Question 5

Describe the epidemiology of haemorrhoids

Answer 5

COMMON
Peak age: 45-65y

Question 6

List 3 symptoms of haemorrhoids

Answer 6

BRIGHT RED PAINLESS bleeding
Anal itching/ irritation
Feeling of incomplete evacuation

Question 7

Describe signs of haemorrhoids

Answer 7

1st or 2nd degree: NOT usually visible on external inspection
Internal: NOT palpable on DRE unless thrombosed

Question 8

List 7 differential diagnoses for haemorrhoids

Answer 8

Anal tags  
Anal fissures  
Rectal prolapse  
Polyps  
Tumours  
Perianal haematoma  
Abscess

Question 9

What primary investigations may be performed for haemorrhoids?

Answer 9

Abdominal examination to r/o other diseases
DRE: prolapsing= obvious
FBC: microcytic anaemia (only if severe prolonged bleeding)

Question 10

What must be remembered when considering the prevalence of haemorrhoids?

Answer 10

Haemorrhoids are common so their presence does NOT mean you shouldn’t consider another source of bleeding

Question 11

What further investigations may be performed for haemorrhoids?

Answer 11

Proctoscopy: to see internal haemorrhoids
Rigid or flexible sigmoidoscopy: to exclude a rectal or sigmoid source of bleeding

Question 12

Give 4 conservative management strategies for haemorrhoids

Answer 12

High-fibre diet
Increase fluid intake
Paracetamol
Cooling packs

Question 13

Describe medical management of haemorrhoids

Answer 13

If constipated: bulk laxatives e.g. ispaghula
Topical steroids relieve pruritis

Question 14

Describe outpatient management of haemorrhoids

Answer 14

Rubber band ligation: bands applied proximal to haemorrhoids which then fall off after a few days

Injection Sclerotherapy: Induces fibrosis of the dilated vein

Question 15

Describe surgical management of haemorrhoids

Answer 15

Haemorrhoidectomy
Haemorrhoidal artery ligation
Haemorrhoidopexy

Question 16

List 3 complications of haemorrhoids

Answer 16

Thrombosis
Soiling
Incarceration

Question 17

What is the prognosis for haemorrhoids?

Answer 17

Often CHRONIC
High rate of recurrence
Surgery can provide long-term relief

Question 18

What is the dentate line? What does this represent?

Answer 18

A line that divides the upper 2/3 + lower 1/3 of the anal canal
2cm from anal verge
Represents the hindgut-proctodeum junction

Question 19

List 4 complications of haemorrhoidectomy

Answer 19

Pain
Bleeding
Incontinence
Anal stricture

Question 20

What are the important negatives to note in haemorrhoids?

Answer 20

Usually ASYMPTOMATIC
Blood NOT be mixed with the stool
ABSENCE of FLAWS: WL, anaemia, CIBH, passage of clotted or dark blood, mucus mixed with stool

Question 21

List 5 complications of injection sclerotherapy

Answer 21

Prostatitis  
Perineal sepsis  
Impotence  
Retroperitoneal sepsis  
Hepatic abscess

Question 22

Describe presentation of acutely thrombosed external haemorrhoid

Answer 22

Significant pain
Purplish, oedematous, tender perianal mass

Question 23

Describe management of acutely thromboses external haemorrhoids

Answer 23

if presents within 72h: consider for excision.

Otherwise patients can usually be managed with stool softeners, ice packs + analgesia.

Sx usually settle within 10 days