Haemorrhoids

Question 1

What is the definition of “haemorrhoids”?

Answer 1

clusters of vascular tissue, SM + connective tissue lined by the normal epithelium of the anal canal

Question 2

What are some causes of haemorrhoids?

Answer 2

decreased VR/increased intra-abd pressure: pregnancy, constipation => staining
portal HT and anorectal varices
increased rectal vein pressure: obesity, prolonged sitting

Question 3

Discuss the grading of haemorrhoids

Answer 3

I - palpable, non-prolapsing + bleeding
II - prolapse w/ straining + defecation, spontaneously reduce +/- bleeding
III - protrude spontaneously or w/ straining, req manual reduction +/- bleeding
IV - chr prolapsed, cannot reduce, often w/ dentate line released from int position +/- bleeding

Question 4

How does a pt w/ haemorrhoids present?

Answer 4

rectal bleeding (painless, fresh after defecation), pain. mucous discharge, pruritis or prolapse

Question 5

How do sx arise from enlarged int haemorrhoids?

Answer 5

Abn swelling of anal cushions => dilation + engorgement of the arteriovenous plexuses => stretching of suspensory mm + eventual prolapse of rectal tissue thru anal canal. Engorged anal mucosa = easily traumatized => rectal bleeding
Prolapse => soiling + mucous discharge (=> pruritis) + predisposes to incarceration + strangulation

Question 6

How can ext haemorrhoids cause sx?

Answer 6

acute thrombosis = usually related to a sp event e.g. physical exertion, straining + constipation, bout of diarrhoea, change in diet.
Pain from rapid distention of innervated skin by clot + surrounding oedema. Pain lasts 7-14 days + resolves w/ resolution of the thrombosis
Occasionally erode the overlying skin + cause bleeding

Question 7

What are some complications of haemorrhoids?

Answer 7

strangulation + thrombosis
ulceration
gangrene
portal pyaemia (septicaemia)
fibrosis

Question 8

How does one manage acutely thrombosed ext haemorrhoids?

Answer 8

Surgical excision of thrombosed vein w/ wound left open (not preferred)
Tx pain, give anti-coagulant, stool softner etc - thrombosed vein will retract in abt 2 wks

Question 9

How does one manage grade I haemorrhoids?

Answer 9

Conservative:
lifestyle mod -> dietary fibre, oral fluids, stool softener, avoidance of straining during defecation
Meds - NSAIDs, daflon (improves venous tone)

Question 10

How does one manage grade II, III & IV haemorrhoids?

Answer 10

Rubber band ligation

Grade III & IV - can do haemorrhoidectomy, but not 1st, 2nd or even 3rd option
Can also do trans-anal haemorrhoidal dearterialization