Haemorrhoids

Question 1

Define

Answer 1

• Anal vascular cushions become enlarged and engorged with a tendency to protrude, bleed or prolapse in the anal canal

Haemorrhoidal cushions are normal anatomical structures located within the anal canal, usually occupying the left lateral and right anterior and posterior positions. As they enlarge, they can protrude outside the anal canal causing symptoms.

Question 2

How do you classify them?

Answer 2

o Internal
• Arise from the superior haemorrhoidal plexus
• Lie ABOVE the dentate line
o External
• Lie BELOW the dentate line
o NOTE: dentate line = a line that divides the upper 2/3 and the lower 1/3 of the anal canal and represents the hindgut-proctodeum junction

Question 3

What are the degrees of haemorrhoids?

Answer 3

o 1st Degree - haemorrhoids that do NOT prolapse
o 2nd Degree - prolapse with defecation but reduce spontaneously
o 3rd Degree - prolapse and require manual reduction
o 4th Degree - prolapse that CANNOT be reduced

Question 4

What’s the aetiology and risk factors?

Answer 4

•	Exact cause is disputed 
•	Caused by disorganisation of the fibromuscular stroma of the anal cushions 
•	Risk Factors
o	Constipation 
o	Prolonged straining 
o	Derangement of the internal anal sphincter 
o	Pregnancy
o	Portal hypertension

Question 5

Epidemiology

Answer 5

• COMMON

* Peak age: 45-65 yrs

Question 6

What are the presenting symptoms?

Answer 6

Bright red rectal bleeding when wiping with tissue and sometimes in bowl

Other symptoms like itching, anal lumps, tenesmus.

Question 7

What are the signs?

Answer 7

• 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
• Differential Diagnosis
o Anal tags
o Anal fissures
o Rectal prolapse
o Polyps
o Tumours

Question 8

What are the appropriate investigations?

Answer 8

• DRE
• Proctoscopy
• Rigid or flexible sigmoidoscopy
o Important to exclude a rectal or sigmoid source of bleeding
o IMPORTANT: haemorrhoids are common so the presence of haemorrhoids does NOT mean that you shouldn’t consider any other source of bleeding

Question 9

How would you manage?

Answer 9

• Conservative
o High-fibre diet
o Increase fluid intake
o Bulk laxatives
o Topical creams (e.g. local anaesthetics)
• Injection Sclerotherapy
o Induces fibrosis of the dilated veins
• Banding
o Barron’s bands are applied proximal to the haemorrhoids
o The haemorrhoid will then fall off after a few days
o Higher cure rate but may be more painful than injection sclerotherapy
• Surgery
o Reserved for symptomatic 3rd and 4th degree haemorrhoids
o Milligan-Morgan haemorrhoidectomy - excision of three haemorrhoidal cushions
o Stapled haemorrhoidectomy is an alternative method
o Post-operatively the patient should be given laxatives to avoid constipation

Question 10

What are the complications?

Answer 10

• Bleeding
• Prolapse
• Thrombosis
• Gangrene

Question 11

What are the complications of sclerotherapy?

Answer 11

o	Prostatitis 
o	Perineal sepsis 
o	Impotence 
o	Retroperitoneal sepsis 
o	Hepatic abscess

Question 12

What are the complications of haemorrhoidectomy?

Answer 12

o Pain
o Bleeding
o Incontinence
o Anal stricture

Question 13

What’s the prognosis?

Answer 13

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