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 SM 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)
What are the complications of Haemorrhoids?
Anaemia
Thrombosis
Describe Haemorrhoid thrombosis
Prolapsing piles strangulated by anal sphincter –> thrombosis –> often fibrose w/i 2/3 weeks
-conservative management w/ cold compress, opioids, 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?
Prolapsing piles
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 Congestion of superior rectal vv -cardiac failure -pregnancy -rectal carcinoma -raised IAP
What is the ddx for rectal bleeding?
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
Describe the venous drainage of the rectum
Superior rectal vv –> Inf mesenteric vv (portal)
Middle/inferior rectal vv –> cavally
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
Avoid straining
Topical analgesia/astringents
Bulk forming laxative
What are the non-conservative management options for haemmorhoids?
Sclerotherapy
Banding
Surgery
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?
3rd/4th degree piles
Stapled haemorrhoidopexy/haemorrhoidal artery ligation
What is a perianal haematoma?
Thrombosed external pile
Covered by sq epithelium –> PAINFUL
