Haemorrhoids Flashcards
Define
Anal vascular cushions become enlarged and engorged with a tendency to protrude, bleed or prolapse in the anal canal
Classification
Internal
- Arise from the superior haemorrhoidal plexus
- Lie ABOVE the dentate line
External
- Lie BELOW the dentate line
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
Causes
- Effects of gravity (our erect posture); ↑anal tone (stress) and effects of straining at stool
- Bleed readily from the capillaries of the underlying lamina propria → Bright red blood
1st Degree - haemorrhoids that do NOT prolapse
2nd Degree - prolapse with defecation but reduce spontaneously
3rd Degree - prolapse and require manual reduction
4th Degree - prolapse that CANNOT be reduced
Risk factors
- Constipation with prolonged straining
- Also caused by (more rare): congestion from a pelvic tumour; pregnancy; CCF; portal HTN
Epidemiology
COMMON
Peak age: 45-65 yrs
Symptoms
Usually ASYMPTOMATIC
- Bleeding
- Bright red blood that is on the toilet paper and drips into the pan after passage of stool
- 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:
- Itching
- Anal lumps
- Prolapsing tissue
NOTE: external haemorrhoids that have thrombosed can be very PAINFUL
Signs
Prolapsing piles will be obvious upon examination Palpable haemorrhoids
Investigations
DRE
Proctoscopy
Rigid or flexible sigmoidoscopy
Important to exclude a rectal or sigmoid source of bleeding
IMPORTANT: haemorrhoids are common so the presence of haemorrhoids does NOT mean that you shouldn’t consider any other source of bleeding
Management
Conservative
- High-fibre diet
- Increase fluid intake
- Bulk laxatives
- Topical creams (e.g. local anaesthetics)
Injection Sclerotherapy
- Induces fibrosis of the dilated veins
Banding
- Barron’s bands are applied proximal to the haemorrhoids
- The haemorrhoid will then fall off after a few days
- Higher cure rate but may be more painful than injection sclerotherapy
Surgery
- Reserved for symptomatic 3rd and 4th degree haemorrhoids
- Milligan-Morgan haemorrhoidectomy - excision of three haemorrhoidal cushions
- Stapled haemorrhoidectomy is an alternative method
- Post-operatively the patient should be given laxatives to avoid constipation
Complications
- Bleeding
- Prolapse
- Thrombosis
- Gangrene
Injection Sclerotherapy Complications
- Prostatitis
- Perineal sepsis
- Impotence
- Retroperitoneal sepsis
- Hepatic abscess
Haemorrhoidectomy Complications
- Pain
- Bleeding
- Incontinence
- Anal stricture
Prognosis
Often CHRONIC
High rate of recurrence
Surgery can provide long-term relief
