Haemorrhoids

Question 1

What are haemorrhoids?

Answer 1

• Abnormal swelling or enlargement of anal vascular cushions
• These usually assist the anal sphincter to maintain continence
• There are 3 - one at 3, 7 and 11 o’clock positions

When patient supine and in this position

Question 2

Classification of haemorrhoids

Answer 2

• According to size
• 1st degree - remain in rectum
• 2nd degree - prolapse through anus on defecation but then reduce
• 3rd degree - prolapse on defectation but need to be manually reduce
• 4th degree - persistent prolapse

Question 3

RF for haemorrhoids

Answer 3

• Excessive straining - from chronic constipation
• Increasing age
• Raised intra-abdominal pressure eg pregnancy, chronic cough or ascites

Question 4

Symptoms of haemorrhoids

Answer 4

• Painless bright red blood PR
• After defecation and seen on paper or covering the pan
• Blood on surface of stool - NOT mixed in
• Can also get itching - chronic mucus discharge and irritation
• Rectal fullnesss or anal lump
• Soiling - due to impaired continence or mucus discharge

Question 5

What can occur to large prolapsed haemorrhoids?

Answer 5

• They can thrombose
• These are very painful
• Present acutely to A&E

Question 6

Examination of haemorrhoids

Warning - lovely pic coming up

Answer 6

• Normal unless prolapsed
• Thrombosed = purple/blue, oedematous, tense and tender peri-anal mass

Question 7

Investigations for ?haemorrhoids

Answer 7

• Proctoscopy
• If prolonged bleeding - FBC + clotting screen
• Colonoscopy - exclude anorectal pathology before surgical intervention if complicated

Question 8

Conservative management - uncomplicated haemorrhoids

Answer 8

• Increase fibre
• Increase fluids
• Laxatives if necessary
• = avoid constipation
• Topical analgesia eg lignocaine gel
• AVOID oral opioid analgesia - worsen constipation

Question 9

Conservative management thrombosed haemorrhoids

Answer 9

• Sitting on ice packs
• Topical lidocaine gel
• Haemorrhoidectomy not recommended if thrombosed due to failure of resolving symptoms and higher risk complications

Question 10

Treatment for 1st and 2nd degree symptomatic haemorrhoids - intervention

Answer 10

• Rubber band ligation
• Draw haemorrhoid to end of suction gun, rubber band placed over neck of haemorrhoid
• In clinic or theatre

Question 11

Surgical options - 2nd and 3rd degree haemorrhoids

Answer 11

• Haemorrhoidal artery ligation - transanal haemorrhoid dearterialisation
• Main vessel supplying identified via dopper - then tied off
• Haemorrhoid infarcts and falls off

Question 12

Surgical option - 3rd and 4th degree haemorrhoids

Answer 12

• Haemorrhoidectomy - esp if unsuitable for banding or ligation
• Haemorrhoidal tissue excised - ensuring internal sphincter muscle remains
• Exposed tissue can be left open (Milligan Morgan) or close mucosa with staples/sutures

Question 13

Main complications following haemorrhoidal surgery and how to avoid one

Answer 13

• Recurrence
• Anal stricturing - avoid this by leaving sufficient skin bridges between excised areas, if haemorrhoids are extensive or circumfertential, may need staged procedures
• Faecal incontinence