Haemorrhoids and Anal Fissures Flashcards
what are haemorrhoids
vascular cushions (which are normally found within the anal canal) which become symptomatic when they expand and can protrude outside of the canal
most likely due to excessive straining either from constipation or diarrhoea
what are the risk factors for haemorrhoids
factors which cause excessive straining:
chronic constipation
chronic diarrhoea
factors which cause increase in intrabdominal pressure:
pregnancy
ascites
chronic cough
space occupying lesion in pelvis
other:
portal hypertension
family history
how do haemorrhoids present
bright red painless PR bleeding
blood is on surface of stool
pruritus
intermittent protuding mass
palpable anal mass may be felt if they are protruding
if pain + perianal mass is present –> haemorrhoid has likely thrombosed (common in external haemorrhoid)
soiling - if grade III/IV
what are the different types of haemorrhoids
internal or external:
internal - originate above dentate line, less likely to cause pain
external - originate below dentate line, often thrombose + cause pain
internal - Grade I-IV
I - don’t prolapse outside of anal canal
II - prolapse on defectation but reduce spontaneously
III - prolapse on defecation but have to be reduced digitally
IV - permanently prolapsed
what are the investigations for haemorrhoids
anoscopic examination - able to see the haemorrhoids
if other worrying symptoms present e.g weight loss, fatigue, change in bowel habit –> flexi sig which should be normal in haemorrhoids
what is the management for haemorrhoids
all patients:
soften stools - increase fibre + fluid intake (conservative management)
grade 1 - conservative management +/- topical corticosteroid for itch
grade II - rubber band ligation
grade III - rubber band ligation
grade IV/external symptomatic, thrombosed/non responsive to outpatient treatment - surgical haemorrhoidectomy
how do thrombosed haemorrhoids present
how are they managed
siginifcant acute pain
purplish, oedematous + tender perianal mass
if patient presents within 72 hours —> haemorrhoidectomy
if over 72hours —> stool softeners, ice packs + analgesia –> settles within 10 days
what is an anal fissure
longitudinal or ellipitical tears of the squamous lining of the distal anal canal
present for < 6weeks –> acute fissure
present for > 6 weeks —> chronic fissure
what are the risk factors for anal fissures
constipation
hard stool
IBD
STIs - HIV, syphilis, herpes
how do anal fissures present
**painful ** bright red PR bleeding
severe pain on defecation, often persists hours after defecation
anal spasm on DRE
most common location for a fissure is the posterior midline, often cause formation of anal skin tag
how are anal fissures diagnosed
clinical diagnosis + visual inspection of anus or palpable on DRE (painful)
how are anal fissures managed
acute fissures (<6 weeks) –> conservative management:
high fibre diet + fluid intake
analgesia - paracetamol or ibruprofen
sitz baths
topical anasthetic for severe pain - lidocaine
Chronic fissures (>6weeks) —> conservative management + GTN
topical GTN for 8 weeks
how do you key differentiating features between haemorrhoids + anal fissures
both present with bright red PR bleeding
main difference is pain
haemorrhoids are painless unless they are thrombosed —> the cushions are visible as purple + clots
fissures are very painful on defecation + this pain persists afterwards
