Haemorrhoids

Question 1

What are clinical haemorrhoids

Answer 1

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.

Question 2

Aetiology of haemorrhoids

Answer 2

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

Question 3

Risk factors for Haemorrhoids

Answer 3

45-65
Constipation
Pregnancy or SOL, pelvis
Hepatic insufficiency
Ascites

Question 4

What is the grading system for Haemorrhoids

Answer 4

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

Question 5

Symptoms of Haemorrhoids

Answer 5

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

Question 6

Signs of Haemorrhoids on examination

Answer 6

tender palpable peri-anal lesion

Question 7

Investigations for Haemorrhoids

Answer 7

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

Question 8

Management for Haemorrhoids

Answer 8

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

Question 9

Complications of Haemorrhoids

Answer 9

Anaemia
Thrombosis
Incarceration
Faecal incontinence
Pelvic sepsis
Anal stenosis

Question 10

Prognosis of Haemorrhoids

Answer 10

Good prognosis after treatment
Low rates of recurrence, although residual symptoms or recurrent symptoms may occur
Surgical haemorrhoidectomy confers the best long-term effect