Haemorrhoids

Question 1

def

Answer 1

anal vascular cushions (which contribute to anal closure) become enlarged + engorged with a tendency to protrude, bleed, prolaspse into the anal canal

Question 2

classifications of haemorrhoids

Answer 2

classified by location
-internal (from superior haemorrhoidal plexus + lie above the dentate line)
-external (from inferior haemorrhoidal plexus + lie below the dentate line)
classified by degree of prolapse
-first degree: do no prolapse
-second degree: prolapse with defaecation but reduce spontaneously)
-third degree: prolapse + require manual reduction
-fourth degree: prolapse + not reversible

Question 3

aetiology

Answer 3

1 associations/risk factors
-constipation
-prolonged straining
-pregnancy
-portal HTN
2 pathogenesis
-excessive straining causes engorgement of anal cushions
-plus hard stools
-causes disruption of tissue organisation, hypertrophy, fragmentation of muscle + elastin fibres + downward displacement
-raised resting anal pressures
-bleeding from pre-sinusoidal arterioles

Question 4

epi

Answer 4

common
45-65yrs
disease of developed world

Question 5

history

Answer 5

commonly asymptomatic
1 bleeding
-bright red blood on toilet paper or dripping into pan after passage of stool
-blood never mixed in with stool
2 absent alarm symptoms
-weight loss
-change in bowel habit
-meleana
3 itching
4 anal lumps
5 severe pain in thrombosed external haemorrhoids

Question 6

examination

Answer 6

first/second degree haemorrhoids not usually apparent on external inspection
uncomplicated haemorrhoids are seen on protoscopy as red granular mucosal swellings, they bulge on straining

Question 7

what are the differential diagnoses for haemorrhoids

Answer 7

anal tags
anal fissure
rectal prolapse
polyps
tumour

Question 8

investigations

Answer 8

sigmoidoscopy to exclude a rectal source of bleeding as haemorrhoids are common and can coexist with colorectal tumours

Question 9

management

Answer 9

conservative
-high fibre diet
-increase fluid intake
-bulk laxatives
-topical creams
local therapy (for first/second degree)
-injection sclerotherapy
-banding
surgical
-for symptomatic 3rd + 4th degree haemorrhoids
-milligan-morgan open haemorrhoidectomy
-stapled haemorroidectomy

Question 10

what topical creams are used for haemorrhoids

Answer 10

contain mild astringents (reduces bleeding) + local anaethetic

Question 11

what is injection sclerotherapy

Answer 11

5% phenol in almond oil is injected above the dentate (no sensory fibres) line into the submucosa above a haemorrhoid
induces inflammation + subsequent fibrosis causing mucosal fixation

Question 12

what is banding

Answer 12

barron’s bands are applied proximal to the haemorrhoid incorporating tissue which falls away after a couple of days
leaves a small ulcer to heal by secondary intention

Question 13

complications

Answer 13

1 bleeding
2 prolapse
3 thrombosis

Question 14

prognosis

Answer 14

often a chronic problem
recurrence of symptoms
surgery can provide long-term relief for severe symptoms