Hemorrhoids

Question 1

Patho

Answer 1

Arise from plexus or cushion of dilated channels and connective tissue

Question 2

External

Answer 2

• distal/ below dentate line

- painful due to sensation is epithelialized skin

Question 3

Internal

Answer 3

• above the dentate line

- less painful because its intestinal

Question 4

Mixed

Answer 4

proximal and distal to dentate line

Question 5

Classification of internal

Answer 5

Grade 1- visualized on anoscopy; may bulge into lumen but doesn’t prolapse below dentate line
Grade 2- prolapse out of anal canal with defecation or with straining but reduces spontaneously
Grade 3- prolapse out of anal canal with defecation/ straining and requires manual reduction
Grade 4- irreducible and may strangulate

Question 6

RF

Answer 6

• aging
• diarrhea
• pregnancy
• pelvic tumors
• prolonged sitting
• straining, chronic constipation
• anticoag/antiplatelet therapy

Question 7

Clinical

Answer 7

• Asymptomatic
• painless bleeding; bright red blood per rectum
• anal pruritis
• prolapse
• pain due to thrombosis

Question 8

Dx tools

Answer 8

Visulaization
Digital Rectal exam
Anoscopy
Endoscopy

Question 9

Essentials for DX

Answer 9

Suspect with:
- bright red blood per rectum
- anal pruritis
- acute onset perianal pain
Visualize hemorrhoids

Question 10

Tx

Answer 10

Dietary- increase water and fiber intake
Toilet habits- avoid lingering
Sitz bath- soaks anus and keeps it clean

Question 11

Office Tx

Answer 11

• banding
• coagulation
• sclerotherapy

Question 12

Initial Tx External and Grade 1/2

Answer 12

• Dietary therapy
• educate about toilet habits
• oral/ local analgesic
• topical agents to reduce swelling/ treat dermatitis (topical astringent and protectants, topical corticosteriods, topical antiinflammatory agents)
• Decrease sphincter spasms (antispasmotic)
• Venoactive agents to increase venous tone
• Banding

Question 13

Who gets surgery?

Answer 13

• sx despite conservative measures
• grade 4 (+/-) strangulation
• Grade 3 with symptoms
• severe pain with thrombosis

Question 14

Surgical Tx

Answer 14

• hemorrhoidectomy
• hemorrhoidal artery ligation
• staple hemmorrhoidectomy

Question 15

Tx Thrombosed Hemorrhoids

Answer 15

Excision and I&D

Question 16

When to refer

Answer 16

• melena, dark red blood per rectum, postural vital signs
• sx suggesting malignancy
• positive fecal occult blood stools
• positive family history of familial polyposis