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Year 3 > Haemorrhoids (GI) > Flashcards

Haemorrhoids (GI) Flashcards

1
Q

What are haemorrhoids?

A

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

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2
Q

What can cause haemorrhoids? (3)

A
  • 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)
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3
Q

What age is haemorrhoids more common in?

A

45 to 65 year olds

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4
Q

What are the two types of haemorrhoids?

A
  • 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)
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5
Q

What can straining cause (haemorrhoids)?

A

Protrusion that may or may not be reduced

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6
Q

What can cause a thrombosed external haemorrhoid?

A

Haemorrhoidal tissues can also become engorged + clots can form

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7
Q

What happens if haemorrhoids become strangulated if blood supply is cut off?

A

Ischaemia

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8
Q

What happens when vascular cushions are strained in defecation with haemorrhoids?

A

Their thin epithelia lining can tear causing rectal bleeding

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9
Q

What is a haemorrhoidal prolapse?

A

When haemorrhoidal tissue bulges outwards

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10
Q

How do haemorrhoids generally present?

A

Painless rectal bleeding or sudden onset of perianal pain with a tender palpable perianal mass

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11
Q

How can internal haemorrhoids be classified?

A
  • 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
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12
Q

What are the clinical features of haemorrhoids? (6)

A
  • 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)
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13
Q

What are the signs of thrombosed haemorrhoids?

A
  • significant pain
  • purplish, oedematous, tender subcutaneous perianal mass
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14
Q

What are the risk factors for haemorrhoids?

A
  • age between 45 to 65 years
  • constipation
  • pregnancy
  • space-occupying pelvic lesions
  • hepatic insufficiency
  • ascites
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15
Q

What are the 1st line investigations for haemorrhoids?

A
  • 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
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16
Q

What is the 1st line diagnostic investigation for haemorrhoids?

A

Anoscopic examination

17
Q

What investigation is done for haemorrhoids to rule out serious pathology?

A

Colonoscopy / flexible sigmoidoscopy

18
Q

What examination can be done for haemorrhoids?

A

Digital rectal examination

19
Q

What differential diagnoses are there for haemorrhoids?

A
  • 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
20
Q

What is the 1st line treatment for all patients with haemorrhoids at presentation?

A

Dietary and lifestyle modification - increased fibre (25-30g) and fluid intake, discourage from excessive straining at stool, moist/gentle cleaning

21
Q

What is the treatment algorithm for grade 1 haemorrhoids?

A
  • dietary and lifestyle modification
  • CONSIDER topical corticosteroids (relieves pruritus)
  • CONSIDER sclerotherapy
  • CONSIDER infrared coagulation
22
Q

What is the treatment algorithm for grade 2 haemorrhoids?

A
  • 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
23
Q

What is the treatment algorithm for grade 3 haemorrhoids?

A
  • dietary and lifestyle modification
  • PLUS rubber band ligation
  • OR haemorrhoid arterial ligation
  • OR stapled haemorrhoidopexy
24
Q

What is the treatment algorithm for grade 4 haemorrhoids?

A

Surgical haemorrhoidectomy (most effective 1st line approach)

25
Q

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?

A

1st line = surgical haemorrhoidectomy

26
Q

Summary of treatments for each grade of haemorrhoids.

A
  • grade 1: dietary and lifestyle modification + topical corticosteroids
  • grade 2&3: rubber band ligation
  • grade 4: surgical haemorrhoidectomy
27
Q

How do we manage thrombosed haemorrhoids?

A
  • in patients with <72h history: analgesia and referral for excision is considered
  • in patients with >72h history: stool softeners, ice packs and analgesia
28
Q

What are some complications of haemorrhoids?

A
  • 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
29
Q

What is the prognosis for haemorrhoids?

A
  • good following treatment - results in resolution/improvement of symptoms with low recurrence rate
  • surgical haemorrhoidectomy has best long term effect with <20% symptom recurrence

Year 3 (22 decks)

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