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 SM 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)

Question 8

What are the complications of Haemorrhoids?

Answer 8

Anaemia

Thrombosis

Question 9

Describe Haemorrhoid thrombosis

Answer 9

Prolapsing piles strangulated by anal sphincter –> thrombosis –> often fibrose w/i 2/3 weeks
-conservative management w/ cold compress, opioids, 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

Prolapsing piles

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
Congestion of superior rectal vv
   -cardiac failure
   -pregnancy
   -rectal carcinoma
   -raised IAP

Question 16

What is the ddx for rectal bleeding?

Answer 16

Haemorrhoids (most common)
Anal fissure (v. tender, skin tag)
Diverticulitis (bloody ‘splash’ in pan, LIF)
Rectal cancer (tenesmus, PR bleeding w/ defecation)
Colon cancer (red blood mixed w/ stool, change in bowel habit)
UC (abdo pain, urgency)
Chron’s (wt loss, chronic diarrhoea)
Massive upper GI bleed (usually maelena)
Trauma
Ischaemic/infective colitis
Angiodysplasia

Question 17

Describe the venous drainage of the rectum

Answer 17

Superior rectal vv –> Inf mesenteric vv (portal)

Middle/inferior rectal vv –> cavally

Question 18

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

Answer 18

Anastomoses of anal cushions are porto-caval

-in portal HTN may give ano-rectal varices

Question 19

What are the conservative management options for haemmorhoids?

Answer 19

Increase fluid intake
Avoid straining
Topical analgesia/astringents
Bulk forming laxative

Question 20

What are the non-conservative management options for haemmorhoids?

Answer 20

Sclerotherapy
Banding
Surgery

Question 21

What are the key features of sclerotherapy?

Answer 21

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

Question 22

What are the key features of banding?

Answer 22

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

Question 23

What are the key features of surgery?

Answer 23

3rd/4th degree piles

Stapled haemorrhoidopexy/haemorrhoidal artery ligation

Question 24

What is a perianal haematoma?

Answer 24

Thrombosed external pile

Covered by sq epithelium –> PAINFUL

Question 25

What are the clinical features of a perianal haematoma?

Answer 25

Acute onset w/ sudden pain & lump at anal verge

• tense
• smooth
• dark-blue
• cherry sized

Question 26

What are the management options for a perianal haematoma?

Answer 26

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