Haemorrhoids Flashcards
What are haemorrhoids and what are the risk factors for developing them?
Haemorrhoids are abnormally enlarged vascular mucosal cushions in the anal canal.
Mainly idiopathic
Risk factors: Essentially increased pressure
- Straining
- Weight lifting
- Pregnancy or ascites
- Chronic cough
- Chronic constipation
- CCF
How are haemorrhoids classified?
They are classified as internal and external haemorrhoids.
Internal haemorrhoids are above the dentate line (2cm above the anal verge.) These are not usually painful as there is no sensory anal nn above the dentate line (only painful if strangulated).
External haemorrhoids are below the dentate line and have sensory innervation and are therefore painful and itchy.
1st degree Haemorrhoids - Confined to anal canal. bleed but don’t prolapse
2nd degree Haemorrhoids - Prolapse on defecation but spontaneously reduce
3rd degree Haemorrhoids - Prolapse on defecation, need to be manually reduced
4th degree Haemorrhoids - Remain prolapsed
Describe the roles of the anal sphincters in faecal continence?
2 Sphinters
Internal anal sphincter: usually tonically contracted (SNS) when it becomes distended a reflex relaxes it slightly (PNS can inhibit the tonic contraction)
External anal sphincter is tonically contracted but can be contracted more by will, tensing your anus. (S4 and voluntary)
What are the symptoms of haemorrhoids?
Fresh bright red rectal bleeding, may be in stool on toilet paper or in underwear.
External: Pain, itching and discomfort
Internal: Discomfort, fullness
Pain from internal haemorrhoids is due to strangulation and is rare.
If haemorrhoids prolapse there may be feelings of not fully voiding their bowel.
What are the complications associated with haemorrhoids?
Skin tags can develop because of repeated haemorrhoid dilatation causing the overlying skin to enlarge and stretch.
Thrombosis may develop if an internal haemorrhoids becomes strangulated. (more painful)
Perianal sepsis may occur but is rare.
Severe or persistent bleeding may lead to anaemia.
Describe the examination and proctoscopy of a patient with haemorrhoids?
On inspection you may see: large haemorrhoids.
DRE: may feel prolapsed haemorrhoids also important to rule out other differentials.
Proctoscopy: A plastic device used to better visualise the anal canal.
Haemorrhoids will be visible as pink mucosal swellings.
Note in patients presenting with rectal bleeding over the age of 40 or rectal bleeding + lower GI symptoms they should be referred for colonoscopy.
Don’t forget an abdominal examination (palpable mass/ enlarged liver)
What are the other differentials of rectal bleeding?
Classify these into fresh blood, blood mixed with stools, and melena
Fresh blood:
- Anal cancer (would expect it to be mixed in)
- Anal fissure (very painful)
Mixed in with stool:
- Colorectal cancer (rectum)
- Ulcerative colitis
- Gastroenteritis
- Diverticulitis
- Ischaemic/infective colitis
Melena:
-Massive upper GI bleed
Other:
- Angiodysplasia
- Trauma
Outline the principles of management in a patient with symptomatic haemorrhoids?
Conservative management:
- Lifestyle changes (increase fibre to help with constipation, exercise, drink plenty of fluids)
- Analgesia (non-constipating such as paracetamol)
Non surgical procedures:
- Rubber band ligation
- Infra-red coagulation
- Sclerosing agents
Surgical:
-Haemorrhoidectomy: reserved for large prolapsing haemorrhoids that are symptomatic and have been unresponsive to other treatments
What is a perianal haematoma?
It is also referred to as a thrombosed external haemorrhoid.
It is caused by rupture of a vein which drains the anus.
How does a perianal haematoma present?
It presents as an a acute onset of a painful tender lump on the anus which cannot be pushed back in. No previous history of haemhorroids required.
Describe how perianal haematoma’s are managed?
Usually self-limiting within a few weeks but very painful:
-Analgesia
If pain intolerable/ if seen early:
- Drainage with syringe under local anaesthetic.
wound left open to heal itself
What is the difference between a thrombosed haemhorroid and a perianal haematomoa?
Thrombosed haemhorroids are due to venous stasis in an existing prolapsed haemhorroid. This can occur when they’re being gripped by the external sphincter, preventing venous outflow.
Perianal haematomas are caused by a ruptured external vein covered by squamous epithelium. This blood then clots causing the haematoma
Both are painful acute swellings around the anus
How do you treat a thrombosed external haemorrhoid?
Conservative nonsurgical treatment (stool softeners, increased dietary fiber, increased fluid intake, warm baths, analgesia) can improve symptoms
Can apply topical nifedipine (Ca channel)
Surgical excision resolves the problem
