Haemorrhoids

Question 1

Definition

Answer 1

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

Question 2

Classification

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

Degree

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

Aetiology

Answer 4

• Exact cause is disputed

* Caused by disorganisation of the fibromuscular stroma of the anal cushions

Question 5

Risk factors

Answer 5

o Constipation
o Prolonged straining
o Derangement of the internal anal sphincter
o Pregnancy
o Portal hypertension

Question 6

Epidemiology

Answer 6

• COMMON

* Peak age: 45-65 yrs

Question 7

Presenting symptoms

Answer 7

• Usually ASYMPTOMATIC

• Bleeding
o Bright red blood that is on the toilet paper and drips into the pan after passage
of stool
o Blood will NOT be mixed with the stool

• ABSENCE of alarm symptoms (weight loss, anaemia, change in bowel habit, passage of
clotted or dark blood, mucus mixed with the stool)

• Other symptoms:
o Itching
o Anal lumps
o Prolapsing tissue

• NOTE: external haemorrhoids that have thrombosed can be very PAINFUL

Question 8

Signs on physical examination

Answer 8

• 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

Question 9

Differential diagnoses

Answer 9

o Anal tags
o Anal fissures
o Rectal prolapse
o Polyps
o Tumours

Question 10

Investigations

Answer 10

• 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 11

Management plan (conservative)

Answer 11

o High-fibre diet
o Increase fluid intake
o Bulk laxatives
o Topical creams (e.g. local anaesthetics)

Question 12

Management plan (intervention)

Answer 12

• 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 13

Possible complications

Answer 13

• Bleeding
• Prolapse
• Thrombosis
• Gangrene

Question 14

Injection sclerotherapy complications

Answer 14

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

Question 15

Haemorrhoidectomy complications

Answer 15

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

Question 16

Prognosis

Answer 16

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