Haemorrhoids

Question 1

What is haemorrhoidal tissue?

Answer 1

Part of normal anatomy which contributes to anal continence. Mucosal vascular cushions found in left lateraling, right posterior and right anterior portions of anal canal (3 o clock, 7 o clock and 11 o clock)

Question 2

What are haemorrhoids?

Answer 2

Said to exist when haemorrhoidal tissue / mucosal vascular cushions become enlarged, congested and symptomatic

Question 3

What are 4 key clinical features of haemorrhoids?

Answer 3

1. Painless rectal bleeding - most common
2. Pruritus
3. Pain: usually not significant unless piles are thrombosed
4. Soiling may occur with third or fourth degree piles

Question 4

What are the 2 types of haemorrhoids and what defines them?

Answer 4

1. External: originate below dentate (pectinate) line; prone to thrombosis, may be painful
2. Internal: originate above dentate line, do not generally cause pain

Question 5

What is the dentate (or pectinate) line?

Answer 5

Line which divdes upper two thirds and lower third of anal canal; represents hindgut-proctodeum junction developmentally. There’s columnar epithelium above the line and stratified squamous epithelium below it

Question 6

What are 2 key differences between external and internal haemorrhoids?

Answer 6

1. External originate below dentate line, internal above
2. Internal do not generally cause pain while external are prone to thrombosis which may be painful

Question 7

What is the grading of internal haemorrhoids?

Answer 7

1. Grade I: do not prolapse out of the anal canal
2. Grade II: prolapse on defecation but reduce spontaneously
3. Grade III: can be manually reduced
4. Grade IV: cannot be reduced

Question 8

What are 6 aspects of the management of haemorrhoids?

Answer 8

1. Soften stools: increase dietary fibre and fluid intake
2. Topical LA and steroids to help symptoms
3. Outpatient treatments: rubber band ligation superior to injection sclerotherapy
4. Surgery
5. New treatments: doppler-guided haemorrhoidal artery ligation, stapled haemorrhoidopexy

Question 9

When is surgery considered to treat haemorrhoids?

Answer 9

Reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments (rubber band ligation/ injection sclerotherapy)

Question 10

What are 2 forms of outpatient treatment for haemorrhoids and which is superior?

Answer 10

1. Rubber band ligation - superior
2. Injection sclerotherapy

Question 11

What is the typical presentation of actuely thrombosed external haemorrhoids?

Answer 11

Present with significant pain. Examination shows purplish, oedematous, tender subcutaneous perianal mass

Question 12

What is the management of acutely thrombosed external haemorrhoids?

Answer 12

If patient presents within 72 hours, then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia

Question 13

How long does it usually take for acutely thrombosed external haemorrhoids to settle?

Answer 13

Usually within 10 days