Haemorrhoids Flashcards
What are Haemorrhoids?
Anal vascular cushions become enlarged + engorged with a tendency to protrude, bleed or prolapse in the anal canal
How can haemorrhoids be classified based on location?
Internal: Lie ABOVE the dentate line
External: Lie BELOW the dentate line
What are the 4 degrees of haemorrhoids?
1st: DONT prolapse
2nd: prolapse with defecation but reduce spontaneously
3rd: prolapse + require manual reduction
4th: prolapse, CANT be reduced
Describe the aetiology of haemorrhoids
Exact cause unknown
Caused by disorganisation of fibromuscular stroma of anal cushions
Vulnerable to trauma, e.g. from hard stools, + bleed from capillaries (blood is bright red) of underlying lamina propria
No sensory fibres thus not painful unless they thrombose when they protrude + are gripped by the anal sphincter, blocking venous return.
List 7 risk factors for haemorrhoids
AGE Constipation Prolonged straining Lifting Derangement of the internal anal sphincter Pregnancy Portal hypertension
Describe the epidemiology of haemorrhoids
COMMON
Peak age: 45-65 yrs
List 3 symptoms of haemorrhoids
Bleeding: Bright red blood on toilet paper + drips into the pan after passage of stool
May have perianal discomfort + feeling of incomplete evacuation
Prolapsing tissue => anal pruritus
Describe signs of haemorrhoids
1st or 2nd degree: NOT usually visible on external inspection
Internal: NOT normally palpable on DRE unless thrombosed
List 7 differential diagnoses for haemorrhoids
Anal tags Anal fissures Rectal prolapse Polyps Tumours Perianal haematoma Abscess
What primary investigations may be performed for haemorrhoids?
Abdominal examination to rule out other diseases
DRE: prolapsing= obvious
FBC: may demonstrate microcytic or hypochromic anaemia (only issue if severe prolonged bleeding)
What must be remembered when considering the prevalence of haemorrhoids?
Haemorrhoids are common so their presence does NOT mean you shouldn’t consider another source of bleeding
What further investigations may be performed for haemorrhoids?
Proctoscopy: to see internal haemorrhoids
Rigid or flexible sigmoidoscopy: to exclude a rectal or sigmoid source of bleeding
Give 4 conservative management strategies for haemorrhoids
High-fibre diet
Increase fluid intake
Bulk laxatives
Topical steroids: avoid prolonged use as can cause atrophy of skin but relieves pruritis
Describe non operative management of 2nd and 3rd degree haemorrhoids
Injection Sclerotherapy: Induces fibrosis of the dilated vein
Banding: Barron’s bands are applied proximal to the haemorrhoids which then fall off after a few days (Higher cure rate but may be more painful than sclerotherapy)
Describe surgical management of symptomatic 3rd and 4th degree haemorrhoids
Milligan-Morgan haemorrhoidectomy: excision of 3 haemorrhoidal cushions
Involves excision of piles +/- litigation of vascular pedicles, as day-case surgery
Scalpel, electrocautery or laser
Stapled haemorrhoidectomy: when large internal component
May result in less pain, shorter hospital stay, quicker return to normal activity
