Haemorrhoids (GI) Flashcards
What are haemorrhoids?
Vascular-rich connective tissue cushions within anal canal that may abnormally enlarge or protrude
NB haemorrhoids are a normal anatomical and functional component of the anal canal; they become pathological and are termed haemorrhoidal disease only when they cause symptoms
What can cause haemorrhoids? (3)
- excessive straining due to chronic constipation or diarrhoea
- increase in intra-abdominal pressure (pregnancy or ascites)
- presence of space-occupying lesions in pelvis (e.g. large ovarian cysts)
What age is haemorrhoids more common in?
45 to 65 year olds
What are the two types of haemorrhoids?
- internal haemorrhoids - lie proximal to the dentate line (originate above the dentate line, generally do not cause pain)
- external haemorrhoids - lie distal to the dentate line (originate below the dentate line, covered by skin, prone to thrombosis and may be more painful)
What can straining cause (haemorrhoids)?
Protrusion that may or may not be reduced
What can cause a thrombosed external haemorrhoid?
Haemorrhoidal tissues can also become engorged + clots can form
What happens if haemorrhoids become strangulated if blood supply is cut off?
Ischaemia
What happens when vascular cushions are strained in defecation with haemorrhoids?
Their thin epithelia lining can tear causing rectal bleeding
What is a haemorrhoidal prolapse?
When haemorrhoidal tissue bulges outwards
How do haemorrhoids generally present?
Painless rectal bleeding or sudden onset of perianal pain with a tender palpable perianal mass
How can internal haemorrhoids be classified?
- grade 1 - protrusion is limited to within the anal canal (bulging purplish-blue veins)
- grade 2 - protrudes beyond the anal canal (on defecation) but spontaneously reduces on cessation of straining (dark pink, glistening, tender masses at anal margin)
- grade 3 - protrudes outside the anal canal and reduces fully on manual pressure
- grade 4 - protrudes outside the anal canal and is irreducible
What are the clinical features of haemorrhoids? (6)
- rectal bleeding - painless bleeding most common, usually bright red blood at defecation/straining (on tissue paper/passed)
- intermittent protrusion
- perianal pain/discomfort - severe in thrombosed external haemorrhoids, may be associated with feeling of incomplete evacuation
- anal pruritus
- tender palpable perianal lesion - acute thrombosis
- anal mass - prolapsing haemorrhoids
- (absence of ALARM symptoms)
What are the signs of thrombosed haemorrhoids?
- significant pain
- purplish, oedematous, tender subcutaneous perianal mass
What are the risk factors for haemorrhoids?
- age between 45 to 65 years
- constipation
- pregnancy
- space-occupying pelvic lesions
- hepatic insufficiency
- ascites
What are the 1st line investigations for haemorrhoids?
- anoscopic examination - most specific and conclusive diagnostic test, visualises anal canal
- colonoscopy/flexible sigmoidoscopy - exclude serious pathology e.g. IBD and cancer in those with suspicious symptoms
- FBC - concerns of anaemia with severe bleeding
- stool for occult haem
What is the 1st line diagnostic investigation for haemorrhoids?
Anoscopic examination
What investigation is done for haemorrhoids to rule out serious pathology?
Colonoscopy / flexible sigmoidoscopy
What examination can be done for haemorrhoids?
Digital rectal examination
What differential diagnoses are there for haemorrhoids?
- anal fissure - painful bleeding on defecation, sentinel skin tag
- Crohn’s disease / ulcerative colitis - rectal bleeding associated with diarrhoea not constipation, Fx
- colorectal cancer - altered bowel habit, abdominal pain, weight loss, anaemia, polyps, Fx
- anal fistula - bleeding with Hx of preceding abscess with intermittent bloody/purulent drainage
- rectal prolapse - protruding mass, discharge, pain, faecal incontinence
What is the 1st line treatment for all patients with haemorrhoids at presentation?
Dietary and lifestyle modification - increased fibre (25-30g) and fluid intake, discourage from excessive straining at stool, moist/gentle cleaning
What is the treatment algorithm for grade 1 haemorrhoids?
- dietary and lifestyle modification
- CONSIDER topical corticosteroids (relieves pruritus)
- CONSIDER sclerotherapy
- CONSIDER infrared coagulation
What is the treatment algorithm for grade 2 haemorrhoids?
- dietary and lifestyle modification
- PLUS rubber band ligation (placed above dentate line, haemorrhoid necroses and sloughs in approx 1wk)
- OR sclerotherapy
- OR infrared coagulation
- OR haemorrhoid arterial ligation
- OR stapled haemorrhoidopexy
What is the treatment algorithm for grade 3 haemorrhoids?
- dietary and lifestyle modification
- PLUS rubber band ligation
- OR haemorrhoid arterial ligation
- OR stapled haemorrhoidopexy
What is the treatment algorithm for grade 4 haemorrhoids?
Surgical haemorrhoidectomy (most effective 1st line approach)
What do we do if there is treatment failure of rubber band ligation, sclerotherapy, infrared coagulation, transanal haemorrhoidal de-arterialisation, or stapled haemorrhoidopexy for haemorrhoids?
1st line = surgical haemorrhoidectomy
Summary of treatments for each grade of haemorrhoids.
- grade 1: dietary and lifestyle modification + topical corticosteroids
- grade 2&3: rubber band ligation
- grade 4: surgical haemorrhoidectomy
How do we manage thrombosed haemorrhoids?
- in patients with <72h history: analgesia and referral for excision is considered
- in patients with >72h history: stool softeners, ice packs and analgesia
What are some complications of haemorrhoids?
- anaemia from excessive bleeding
- thrombosis (sudden perianal pain + tender nodule near anal canal, often after vigorous activity, engorged tissue –> clots)
- incarceration (prolapsing tissue cannot be reduced into anal canal –> urgent surgical haemorrhoidectomy)
- faecal incontinence
- ulceration
- gangrene
- pelvic/perianal sepsis
What is the prognosis for haemorrhoids?
- good following treatment - results in resolution/improvement of symptoms with low recurrence rate
- surgical haemorrhoidectomy has best long term effect with <20% symptom recurrence
