Haemorrhoids Flashcards
outline a typical presentation of haemorrhoids
Painless fresh blood on toilet paper and in the toilet bowl
If large => fullness, tenesmus, soiling
Important to look at degree of haemorrhoids when determining the management
Define haemorrhoids?
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.
outline the classification of haemorrhoids?
Internal
- Arise from the superior haemorrhoidal plexus
- Lie ABOVE the dentate line
External
- Lie BELOW the dentate line
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
outline the degrees of haemorrhoids?
1st Degree - haemorrhoids that do NOT prolapse
2nd Degree - prolapse with defecation (extend to outside rectum when excreting) but reduce spontaneously
3rd Degree - prolapse and require manual reduction
4th Degree - prolapse that CANNOT be reduced
what are the risk factors for haemorrhoids?
Age- between 45-65 years old
constipation
pregnancy or space occupying lesion
INCREASED INTRA-ABDOMINAL PRESSURE
summarise the epidemiology of haemorrhoids?
COMMON
Peak age: 45-65 yrs
outline the aetiology of haemorrhoids?
Exact cause is disputed
The 3 anal cushions are at 3, 7 and 11 o’clock – where the 3 major arteries that feed the vascular plexuses enter the anal canal. They are attached by smooth muscle and elastic tissue, but are prone to displacement and disruption, either singly or together. This may be due to effects of gravity, increased anal tone, and the effects of straining – this can cause them to become bulky and loose, and protrude to form piles.
They are vulnerable to trauma, e.g. from hard stools, and bleed from capillaries of underlying lamina propria. As it is from capillaries, the blood is bright red.
As there are no sensory fibres, piles are not painful unless they thrombose when they protrude and are gripped by the anal sphincter, blocking venous return.
what are the presenting symptoms of haemorrhoids?
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)
May have perianal discomfort and feeling of incomplete evacuation
Other symptoms:
Itching
Anal lumps
Prolapsing tissue => anal pruritus
NOTE: external haemorrhoids that have thrombosed can be very PAINFUL
what are the signs of haemorrhoids on physical examination?
Lump on DRE
3/4th may be visible on inspection
HAEMORRHOIDS USUALLY VISIBLE ON PROCTOSCOPY
What are the differentials for haemorrhoids?
Anal tags
Anal fissures
Rectal prolapse
Polyps
Tumours
Perianal haematoma
Abscess
what are the appropriate investigations for haemorrhoids?
Proctoscopy – to see internal haemorrhoids
DRE – prolapsing piles are obvious
FBC- may demonstrate microcytic/ hypochronic anaemia
colonoscopy/ flexible sigmoidoscopy - exclude serious IBD or cancer
stool for occult haem- only do this if no haemorrhoidal tissue seen on examination
what us the first degree management of haemorrhoids?
conservative – if this fails, use non-operative measured
- High-fibre diet
- Increase fluid intake
- Bulk laxatives
- Topical steroids – avoid prolonged use as can cause atrophy of skin but used to relief pruritic symptoms
what is the 2nd and 3rd degree management of haemorrhoids?
non-operative measures e.g. rubber band ligation, sclerotherapy
- Injection Sclerotherapy - Induces fibrosis of the dilated vein
- Banding - Barron’s bands are applied proximal to the haemorrhoids so it will then fall off after a few days; Higher cure rate but may be more painful than injection sclerotherapy
what is the 4th degree management of haemorrhoids?
SURGERY
Reserved for symptomatic 3rd and 4th degree haemorrhoids
Milligan-Morgan haemorrhoidectomy - excision of three haemorrhoidal cushions
Involves excision of piles +/- litigation of vascular pedicles, as day-case surgery
Scalpel, electrocautery or laser may be used
Stapled haemorrhoidectomy is an alternative method
May result in less pain, shorter hospital stay, quicker return to normal activity
Used when there is a large internal component but has higher recurrence rate than conventional surgery
Post-operatively the patient should be given laxatives to avoid constipation
Complications of haemorrhoidectomy are RARE but can include: bleeding, fissure, fitsula, abscess, stenosis, urinary retention, incontinence, soiling
What are the possible complications of haemorrhoids?
Bleeding
Prolapse
Thrombosis
- Severe pain
- Purplish oedematous perianal mass
- If <72hrs surgical excision
Strangulation
- Severe pain
- Urgent haemorrhoidectomy
Gangrene
