Haemorrhoids
Definition
Clinical Features
Symptoms
Bright red bleeding (on top of stools, on toilet bowl, on tissue), may have mucous discharge or pruitus ani, pain if below dentate line, thrombosed or strangulated, Hx of constipation or straining, absence of LOW, tenesmus, or change in bowel habit
Signs
signs of anaemia, PR exam (prolapsing haemorrhoids visible), may present with other signs of portal HTN such as hepatosplenomegaly and dilated superficial veins, otherwise normal abdo exam
Investigations
Imaging: protoscopy to see internal haemorrhoids, sigmoidoscopy if indicated
Management
1. Medical and lifestyle - fluid, fiber, keep fit, topical analgesia, stool softeners, topical steroids only for interim. If fail, proceed to non operative Mx below
2. Non operative - rubber band ligation, sclerosant. If fail, proceed to surgical Mx
3. Surgery. Early surgery recommended for prolapsed thrombosed haemorrhoids, but with analgesics, ice packs and stool softeners, pain usually resolves in a couple of weeks
Source
OHCM 9th Ed 2014
Harrison's 18th Ed 2012
Toronto Notes 2012
- dilated anal cushions at 3,7,11 o’clock, due to gravity, or increased hydrostatic pressure in venous plexus from straining, pregnancy, pelvic tumour or portal hypertension
- can be external (below dentate line), internal, thrombosed, strangulated or bleeding
- No sensory fibers above dentate line, hence internal usually not painful unless they protrude and get thrombosed
- classification: 1. remain in rectum, 2. prolapse through anus, but spontaneously reduce, 3. requires digital reduction, 4. persistently prolapsed
Clinical Features
Symptoms
Bright red bleeding (on top of stools, on toilet bowl, on tissue), may have mucous discharge or pruitus ani, pain if below dentate line, thrombosed or strangulated, Hx of constipation or straining, absence of LOW, tenesmus, or change in bowel habit
Signs
signs of anaemia, PR exam (prolapsing haemorrhoids visible), may present with other signs of portal HTN such as hepatosplenomegaly and dilated superficial veins, otherwise normal abdo exam
Investigations
Imaging: protoscopy to see internal haemorrhoids, sigmoidoscopy if indicated
Management
1. Medical and lifestyle - fluid, fiber, keep fit, topical analgesia, stool softeners, topical steroids only for interim. If fail, proceed to non operative Mx below
2. Non operative - rubber band ligation, sclerosant. If fail, proceed to surgical Mx
3. Surgery. Early surgery recommended for prolapsed thrombosed haemorrhoids, but with analgesics, ice packs and stool softeners, pain usually resolves in a couple of weeks
- Rubber band ligation has the lowest recurrence rates
Source
OHCM 9th Ed 2014
Harrison's 18th Ed 2012
Toronto Notes 2012