Hemorroids

Question 1

What are haemorrhoids?

Answer 1

Clusters of vascular tissue, smooth muscle and connective tissue lined by normal epithelium of the anal canal

Question 2

What are the risk factors?

Answer 2

1. Decreased venous return and increased intra-abdominal pressure (eg pregnancy, constipation, straining)
2. Increased rectal vein pressure (obesity, prolonged sitting)
3. Age

Question 3

Distinguish between internal and external hemorrhoids.

Answer 3

Internal Hemorrhoids:
1. Rectal Bleeding
- painless fresh bright red after defecation: coating stools, spotting toilet tissue, dripping into the bowl, not mixed with stools
- comes and goes
2. Mucus Discharge
3. Pruritus
4. Prolapse

External Hemorrhoids:
1. Asymptomatic
2. Extreme pain 2’ to acute local thrombosis
3. Painful perianal subcutaneous nodule
- pain increases/constant for 2-3 days, resolves with spontaneous reabsorption of clot, pressure necrosis of overlying skin, gradual decompression

Question 4

What is the pathophysiology for rectal bleeding and rectal prolapse?

Answer 4

Abnormal swelling of the anal cushions causes dilation and engorgement of the arteriovenous plexuses. The engorged, thin and friable anal mucosa is easily traumatised, leading to rectal bleeding that is typically bright red due to high blood oxygen in the arteriovenous anastomoses.

Suspensory muscles get stretched and eventually lead to rectal prolapse - prolapse leads to soiling and mucus discharge, triggering pruritus and predisposes to incarceration and strangulation.

Question 5

What are the complications of hemrrhoids?

Answer 5

1. Strangulation and Thrombosis
2. Ulceration
3. Gangrene
4. Portal Pyema
5. Perianal Sepsis

Question 6

On the basis of origin, location, innervation, pain and venous drainage

Answer 6

Question 7

What is the classification for internal hemorrhoids?

Answer 7

Banov.

Question 8

What is the management of external hemmorhoids?

Answer 8

1. Acute Thrombosis
   - 24-72h: Surgical Excision of thrombosed vein outside the muco-cutaneous junction with wound left open
   - 72h: non-surgical management, symptomatic (sitz bath, stool softener, analgesia)
2. Perianal Skin Tag
   - Symptomatic - excise under LA

Question 9

What is the treatment for grade 1 and 2 internal hemorrhoids?

Answer 9

Question 10

What is the treatment for grade 3 and 4 internal hemorrhoids?

Answer 10