Hemorrhoids

• • 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

Epidemiology

• • 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

Symptoms and Signs

• • 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

Laboratory Findings

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

Imaging Findings

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

• • Anal fissure

  • Anal ulcer

  • Anorectal malignancy

  • Inflammatory bowel disease

  • Diverticular disease

  • Rectal prolapse

  • Condylomata acuminata

Rule Out

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

• • Evaluate for GI sources for anemia

  • History of straining

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

When to Admit

• • Infection or impending necrosis of thrombosed hemorrhoid

  • Perianal sepsis

• • 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

Surgery

Indications

• • Failure of medical management

  • Strangulated, thrombosed hemorrhoids

Contraindications

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

  • Care should be exercised with banding in immunocompromised patients ...