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  • • Internal hemorrhoids originate above dentate line, covered by mucosa

    • External hemorrhoids are vascular complexes covered by anoderm, below dentate line

    • Function as vascular pillows, protect the anal canal during defecation

    • No correlation between constipation and hemorrhoids

    • Internal hemorrhoids classification:

    • -First-degree: Bleed

      -Second-degree: Bleed and prolapse but spontaneously reduce

      -Third-degree: Bleed, prolapse, and require manual reduction

      -Fourth-degree: Incarcerated

    • Internal hemorrhoids become symptomatic when chronic engorgement leads to tissue laxity and tissue prolapse into the anal canal

    • External hemorrhoids become symptomatic with thrombosis

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Epidemiology

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  • • May more commonly develop in younger men and older women

    • Hemorrhoids may develop in younger men due to higher resting pressure within the anal canal

    • Hemorrhoids may develop in older women due to chronic straining, leading to vascular engorgement and dilatation

    • Become engorged with increased intra-abdominal pressure as in obesity, pregnancy, lifting, straining

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Symptoms and Signs

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  • • Internal hemorrhoids

    • -Cause bright red blood per rectum, mucus discharge

      -Sense of rectal fullness but are painless

      -May prolapse into the anal canal and may become strangulated and necrotic

    • External hemorrhoids

    • -Sudden, severe perianal pain, itching

      -May be accompanied by a skin tag

    • Thrombosed external hemorrhoids

    • -Tense, tender subcutaneous mass

      -Purple-black discoloration

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Laboratory Findings

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  • • Chronic bleeding from internal hemorrhoids may cause anemia (rare)

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Imaging Findings

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  • Defecography: May help define cause of obstructed defecation such as rectal prolapse

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  • • Anal fissure

    • Anal ulcer

    • Anorectal malignancy

    • Inflammatory bowel disease

    • Diverticular disease

    • Rectal prolapse

    • Condylomata acuminata

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Rule Out

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  • • Other causes of anemia should be ruled out before attributing anemia to hemorrhoids

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  • • Evaluate for GI sources for anemia

    • History of straining

    • Defecography may be useful to evaluate for obstruction and rectal prolapse

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When to Admit

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  • • Infection or impending necrosis of thrombosed hemorrhoid

    • Perianal sepsis

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  • • Initial medical management recommended for first- and most second-degree hemorrhoids

    • Dietary alteration, addition of bulking agents, stool softeners, increased liquid intake, sitz baths

    • Decreasing time spent on commode

    • Elastic band ligation:

    • -Band placed at base results in sloughing and scar formation

      -Must be placed above dentate line

    • Sclerotherapy

    • -May be efficacious for bleeding hemorrhoids

      -Sclerosant is injected into submucosal connective tissue to induce inflammation and scarring

    • Excisional hemorrhoidectomy

    • -For third- and fourth-degree lesions and incarcerated internal hemorrhoids

      -Tissue is excised, vascular pedicle ligated

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Surgery

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Indications

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  • • Failure of medical management

    • Strangulated, thrombosed hemorrhoids

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Contraindications

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  • • Patients receiving anticoagulants should be treated with excisional hemorrhoidectomy instead of band ligation

    • Care should be exercised with banding in immunocompromised patients (high risk for perineal sepsis)

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Medications

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