Haemorrhoids Flashcards
What are clinical haemorrhoids
Clinical haemorrhoids = enlargement of the haemorrhoidal cushions that protrude outside the anal canal to cause symptoms
Haemorrhoidal cushions = normal anatomical structure located within the anal canal, usually occupying the left lateral and right anterior and posterior positions.
Aetiology of haemorrhoids
Excessive/repetitive/prolonged straining (chronic constipation, diarrhoea)
Causes downward stress on vascular haemorrhoids cushions -> haemorrhoids pulled lower -> cushions engorge -> thin epithelial lining tears -> bleeding -> enlargement -> protrusion -> tenesmus
Also increased intra-abdominal pressure (pregnancy, ascites)
Presence of SOL in the pelvis
Risk factors for Haemorrhoids
45-65
Constipation
Pregnancy or SOL, pelvis
Hepatic insufficiency
Ascites
What is the grading system for Haemorrhoids
Grade 1 - protrusion is limited to within the anal canal, no prolapse
Grade 2 - protrudes beyond the anal canal but spontaneously reduces on cessation of straining.
Grade 3 - protrudes outside the anal canal and reduces fully on manual pressure.
Grade 4 - protrudes outside the anal canal and is irreducible.
External = located in the distal canal, distal to the dentate line and covered by sensate anoderm or skin
Symptoms of Haemorrhoids
Rectal bleeding - often PAINLESS (bright red blood on defection/straining/cleaning/on bowl)
Peri-anal pain/discomfort (severe in thrombosed external haemorrhoids, painless above the dentate line, painful below)
Tenesmus
Anal pruritus
Palpable mass
Signs of Haemorrhoids on examination
tender palpable peri-anal lesion
Investigations for Haemorrhoids
Anoscopic examination: shows haemorrhoids
Stool for occult haem: +ve (unnecessary unless nothing seen on exam)
FBC: may show anaemia (prolonged bleeding)
Colonoscopy/flexible sigmoidoscopy: usually normal, may reveal other pathologies
Management for Haemorrhoids
Conservative: diet and lifestyle mods Increase fibre 20-30g Adequate fluid intake Avoid straining on spending excessive time on the toilet Moist and gentle cleaning
Grade I - topical corticosteroids e.g. hydrocortisone
Grade II - Rubber band ligation, sclerotherapy, infrared photocoagulation, haemorrhoids arterial ligation, stabled haemorrhoidoplexy
Grade III - rubber band ligation, stabled haemorrhoidoplexy
Grade IV - Surgical haemorrhoidectomy
Complications of Haemorrhoids
Anaemia
Thrombosis
Incarceration
Faecal incontinence
Pelvic sepsis
Anal stenosis
Prognosis of Haemorrhoids
Good prognosis after treatment
Low rates of recurrence, although residual symptoms or recurrent symptoms may occur
Surgical haemorrhoidectomy confers the best long-term effect