INTERNAL HEMMRHOID

Question 1

Pertinent anatomy of a patient with internal hemorrhoids

Answer 1

(1) Internal Hemorrhoids
(a) Located above the dentate line
(b) Subepithelial Cushions of the anorectum
1) Submucosa
a) Connective tissue
b) Blood vessels
2) Muscularis
(c) No nervous innervation

Question 2

normal anatomic structures of the anorectum and are
universally present unless a previous intervention has taken place.
(2) They occur in all adults and contribute to normal anal pressures and ensure a water- tight
closure of the anal canal.

Answer 2

Hemorrhoidal venous cushions

Question 3

Because of their rich vascular supply, highly sensitive location, and tendency to engorge
and prolapse, ______ are common causes of anal pathology.

Answer 3

hemorrhoidal venous cushions

Question 4

subepithelial vascular cushions consisting of connective tissue,
smooth muscle fibers, and arteriovenous communications between terminal branches of
the superior rectal artery and rectal veins.

Answer 4

Internal hemorrhoids

Question 5

Internal hemorrhoids commonly occur in three primary locations:

Answer 5

right anterior, right posterior and

left lateral.

Question 6

nerve supply? pain? (internal hemorrhoids)

Answer 6

They lack a nerve supply so are not painful when present

Question 7

Hemorrhoids may become symptomatic as a result of

Answer 7

activities that increase venous
pressure, resulting in distention and engorgement.
Straining at stool, constipation, prolonged sitting, pregnancy, obesity, and low-fiber diets

Question 8

Physical Findings

Answer 8

usually painless bleeding,
prolapse, and mucoid discharge
Bleeding is manifested by bright red blood that may range from streaks of blood visible
on toilet paper or stool to bright red blood that drips into the toilet bowl after a bowel
movement

Question 9

Stages of Internal Hemorrhoids

Answer 9

(a) Initially, internal hemorrhoids are confined to the anal canal (stage I).
(b) Over time, the internal hemorrhoids may gradually enlarge and protrude from the anal opening. At first, this mucosal prolapse occurs during straining and reduces
spontaneously (stage II).
(c) With continued progression, the prolapsed hemorrhoids may require manual
reduction after bowel movements (stage III) or may remain chronically protruding
and unresponsive to manual reduction (stage IV).

Question 10

Chronically prolapsed hemorrhoids may result in a sense of

Answer 10

fullness or
discomfort and mucoid perianal discharge, resulting in irritation and soiling of
underclothes.

Question 11

Are internal hemorrhoids palpable

Answer 11

uncomplicated internal hemorrhoids are neither palpable nor

painful.

Question 12

Differential Diagnosis

Answer 12

(a) anal fissure or fistula,
(b) neoplasms of the distal colon or rectum,
(c) ulcerative colitis or Crohn colitis,
(d) infectious proctitis, or
(e) rectal ulcers.

Question 13

Lab

Answer 13

None

Question 14

RAD

Answer 14

Colonoscopy should be performed in all patients with hematochezia to exclude disease in
the rectum or sigmoid colon that could be misinterpreted in the presence of hemorrhoidal
bleeding

Question 15

Initial Care

Answer 15

(1) In acute onset stay with treatment protocol.
(2) Patients who present with Stage 3 (problematic) Stage 4 require further assessment for
surgical correction.