Hemorrhoid

Question 1

Etiology of hemorrhoids ?

Answer 1

1. Excessive straining (e.g., from chronic constipation, frequent bowel movements, chronic cough, heavy lifting, benign prostatic hyperplasia)
2. Extended periods of sitting (e.g., due to occupation or sedentary lifestyle)
3. Connective tissue disorder (e.g., Ehlers‑Danlos syndrome, scleroderma)
4. Pregnancy

Question 2

Why pregnancy increase risk of hemorrhoids? Which trimester?

Answer 2

Mainly in the third trimester

due to hormonal changes and increased intra-abdominal pressure

Question 3

Internal hemorrhoids stages ?

Answer 3

I : Hemorrhoids do not prolapse (only project into the anal canal); above the dentate (pectinate) line; reversible; often bleed

II : Prolapse when straining, but spontaneously reduce at rest.

III: Prolapse when straining; only reducible manually

IV : Irreducible prolapse; may be strangulated and thrombosed with possible ulceration

Question 4

Anatomy of the anal canal ?

Answer 4

1. Anal cushions
2. Anal columns
3. Anal sinuses
4. Dentate line.
5. External anal sphincter
6. Internal anal sphincter

Question 5

What is Anal cushions ? Location ? Role ? Physiology of defecation?

Answer 5

** Areas of thickened anal mucosa that consist of arteriovenous blood vessels (corpus cavernosum recti), smooth muscle (e.g., Treitz muscle), and fibroelastic tissue (e.g., collagen, elastic fibers)

** Located at 11, 7 and 3 o’clock in the lithotomy position (right anterior, right posterior, and left lateral position)

** Play an important role in maintaining continence by enabling tight closure of the rectum - Adequate anal tone is provided by the internal and external anal sphincters, including the rectal mucosa; which collectively form the anal sphincter complex.

** Defecation causes contraction of supportive structures (e.g., Treitz muscle) → compression of anal cushions → increased diameter of the anal canal for adequate passage of stool

Question 6

What is Anal columns ?

Answer 6

longitudinal folds of mucous membrane that are fused at their inferior ends by transverse folds (anal valves)

Question 7

What is Anal sinuses?

Answer 7

small, mucus-secreting pouches between the anal columns above the anal valves

Question 8

What is Dentate line?

Answer 8

Circular separation line formed by the fusion of anal valves (hindgut-proctodeum junction)
Divides anal canal into an upper and lower part

Question 9

External anal sphincter Composed of ?consist of ? Function ? innervation ?

Answer 9

1. Subcutaneous external sphincter: surrounds lower third of anal canal
2. Superficial external sphincter
3. Deep external sphincter

Consists of skeletal muscle

functions to open and close the anal canal and opening

Innervated by the pudendal nerve and under voluntary control

Question 10

Internal anal sphincter location ? Consist of ? Innervation ?

Answer 10

Surrounds upper two-thirds of anal canal

Consists of involuntary circular smooth muscle and is responsible for ∼ 85% of the resting pressure of the anal canal

Innervated by the enteric nervous system

Question 11

Which sphincter responsible for responsible for ∼ 85% of the resting pressure of the anal canal ?

Answer 11

Internal anal sphincter

Question 12

Characteristics of the anal canal above and below the dentate line:

1. Embryologic origin
2. Epithelium
3. Arterial supply
4. Venous drainage
5. Lymphatic drainage
6. Innervation
7. Clinical relevance

Answer 12

Above
1. Endoderm (from the hindgut).
2. Simple columnar epithelium.
3. Superior rectal artery (branch of the inferior mesenteric artery)
4. Internal hemorrhoidal plexus → superior rectal vein (drains into the inferior mesenteric vein → splenic vein → portal vein → hepatic veins → inferior vena cava)
5. Internal iliac lymph nodes
6. Visceral
Sympathetic: inferior mesenteric plexus
Parasympathetic: inferior hypogastric plexus and pelvic splanchnic nerves
7. Internal hemorrhoid formation
Development of adenocarcinoma
Anorectal varices

Below  1. Ectoderm (from the cloaca) 2. Stratified nonkeratinized squamous epithelium (known as anal pecten) 3. Inferior rectal artery (branch of the internal pudendal artery) 4. External hemorrhoidal plexus → inferior rectal vein (drains into the internal pudendal vein → internal iliac vein → common iliac vein → inferior vena cava) 5. Superficial inguinal lymph nodes 6. Somatic: inferior rectal nerve (branch of the pudendal nerve) 7. External hemorrhoid formation Development of squamous cell carcinoma Anal fissures

Question 13

Hemorrhoids are classified as ?

Answer 13

internal , external , or mixed

Internal: Superior hemorrhoidal plexus; above the dentate line (pectinate line)
External: Inferior plexus; below the dentate line
Mixed: Above and below the dentate line

Question 14

Pain due to Internal hemorrhoids caused by :

Answer 14

1. Prolapse of internal hemorrhoids, with possible incarceration and strangulation, may cause pain by triggering an anal sphincter complex spasm.
2. possible ischemia and necrosis of internal hemorrhoids → worsening anal sphincter complex spasm → potential external hemorrhoid thrombosis → cutaneous pain
3. Bleeding and/or prolapsed internal hemorrhoids irritate sensitive perianal skin → perianal itching

Question 15

Since the internal anal cushions are not lined with…………, they lack……………. , which normally transmits……….. . Instead, pain is only felt in the event of an ……………. .

Answer 15

1. skin
2. cutaneous innervation
3. pain
4. anal sphincter complex spasm

Question 16

Internal hemorrhoids Develop ………. the dentate line, which is not innervated by ……………. ; distension (does/ doesn’t) cause pain

Answer 16

1. above
2. cutaneous nerves
3. doesn’t

Question 17

Pain due to External hemorrhoids caused by ?

Answer 17

1. distention of this innervated skin due to a clot or edema results in severe pain.— Develop below the dentate line, which is innervated by cutaneous nerves
2. Acute thrombosis triggers cutaneous pain, lasting 7–14 days → thrombosis resolves → residual skin or skin tags of distended anal skin

Question 18

Clinical feature of internal hemorrhoids?

Answer 18

1. Often painless, bright red bleeding at the end of defecation (potentially dull, aching pain with severe sphincter spasm)
2. Perianal mass in the event of prolapse
3. Pruritus
4. Discharge (containing mucus or fecal debris)
5. Ulceration (in grade IV)

Question 19

External hemorrhoids Clinical?

Answer 19

1. Painful perianal mass : Thrombosed external hemorrhoids manifest with sudden-onset pain with anal swelling; the swelling may have a characteristic purplish hue
2. Pruritus

Question 20

Clinical examination of hemorrhoids ?

Answer 20

Inspect perianal area for external hemorrhoids and prolapsed internal hemorrhoids; exclude other conditions (e.g., anal skin tags, polyps).

Digital rectal examination may show abnormal masses or tenderness or bleeding.

Question 21

Diagnosis of hemorrhoids?

Answer 21

** Hemorrhoids are a clinical diagnosis.

• • Anoscopy
• For assessing the anus and distal rectum
• Useful when hemorrhoids are suspected but rectal examination is inconclusive
• Internal hemorrhoids are difficult to palpate unless thrombosed. Exclusion or diagnosis of hemorrhoids should, therefore, be confirmed with direct visualization during anoscopy. Anoscopy under anesthesia may be necessary if there is significant anal sphincter spasm.

** In addition, proctoscopy may be used to support anoscopy findings.

** Other procedures
Flexible sigmoidoscopy, colonoscopy, or barium enema: to exclude
1. suspected malignancy (especially in patients over the age of 40)
2. presence of risk factors for colorectal cancer
3. red flags for colorectal cancer

Question 22

Anoscopy vs proctoscope ?

Answer 22

Anoscopy: assessing the anus and distal rectum

Proctoscopy: camera is used to assess anus , rectum and/ or sigmoid colon

Question 23

Ddx of hemorrhoids ?

Answer 23

1. Anal skin tags: folds of skin at the anal verge, often at 6 o’clock in the lithotomy position (benign, but may become inflamed or itch)
2. Hypertrophied anal papillae
3. Polyps
4. Anal and colorectal carcinoma
5. Anal fissures
6. Anorectal varices
7. Proctitis
8. Condyloma acuminata
9. Inflammatory bowel disease (often associated with anal fistulas and abscesses)

Question 24

In hemorrhoids , Always consider the possibility of concurrent ……….. !

Answer 24

colorectal carcinoma

Question 25

Treatment of hemorrhoids?

Answer 25

Hemorrhoids should only be treated in a symptomatic patient!

1. Conservative treatment
2. Outpatient treatment
3. Surgical treatment (stages III–IV)

Question 26

Conservative treatment and its indication ?

Answer 26

Indications: grade I–II internal hemorrhoids and external hemorrhoids

Interventions

1. Lifestyle modifications: weight loss, exercise, high fiber diet, avoid fatty and spicy foods, increase water intake
2. Alter stool habits (e.g., avoid excessive straining or > 5 min periods on the toilet)
3. Sitz baths
4. Stool softeners (e.g., docusate)
5. Topical or suppository analgesia (e.g., lidocaine)
6. Topical anti‑inflammatory (e.g., hydrocortisone, especially with pruritus, but no longer than 1 week)
7. Topical antispasmodic agents (e.g., nitroglycerin)

Question 27

Outpatient treatment and its indication?

Answer 27

Indications: all internal hemorrhoids with symptoms persisting despite conservative treatment and grade III internal hemorrhoids

Interventions
Rubber band ligation (RBL)
Sclerotherapy
Infrared coagulation

A rubber band is placed at the apex of the internal hemorrhoid → triggers an inflammatory response within hemorrhoidal tissue → subsequent fibrosis results in prolapsed hemorrhoid moving to its original position → improved venous drainage and shrinkage of hemorrhoid.

The injection of irritant chemicals (e.g., ethanol, sodium tetradecyl sulfate) into a vascular space or body cavity to cause inflammation, fibrosis, and obliteration of the said space. Used to treat varicose veins, hemorrhoids, esophageal varices, hydatid cysts, malignant pleural effusion, and intracranial aneurysms.

Infrared heat is applied to coagulate and induce fibrosis of hemorrhoidal tissue.

Question 28

Surgical treatment & It’s indication ?

Answer 28

Indications: grade IV internal hemorrhoids and no improvement of condition after clinical interventions

Interventions
Arterial ligation of hemorrhoids (HAL)
Submucosal hemorrhoidectomy
Ferguson approach (closed approach )
Milligan‑Morgan approach (open approach )
Stapled hemorrhoidopexy (e.g., using the Longo procedure): only effective for internal hemorrhoids : The abnormal hemorrhoid tissue is removed, while the remaining tissue is stapled to its proper anatomical location.

Question 29

What is Ferguson approach (closed approach ) & Milligan‑Morgan approach (open approach ) ?

Answer 29

Ferguson approach : Excision of all three arteriovenous cushions and primary skin closure.

Milligan‑Morgan approach : Excision of all three arteriovenous cushions while the skin is left open for up to eight weeks to heal by secondary intention.

Question 30

Complication of hemorrhoids?

Answer 30

1. Hemorrhoid disease
2. Postoperative

Hemorrhoid disease
Internal: prolapse of internal hemorrhoid → accumulation of mucus and fecal debris in external anal tissue → local irritation and inflammation
External: may become acutely thrombosed (e.g., with excessive straining) → necrosis of overlying skin and bleeding

Postoperative
Pain
Thrombosis
Bleeding
Anal stricture/stenosis
Perineal/pelvic sepsis :This complication is an emergency that often occurs in immunocompromised individuals. It presents with perineal/pelvic pain, fever, and dysuria.