Haemorrhoids

Question 1

Definition

Answer 1

Abnormal swelling or enlargement of the anal vascular cushions.

Question 2

Explain anal vascular cushions.

Answer 2

Assist the anal sphincter in maintaining continence

Three vascualr cushions in 3, 7 and 11 clock positions.

They can become abnormally enlarged and when they become pathological and symptomatic they are termed haemorrhoids.

Question 3

Classification

Answer 3

According to size

1st degree = Remains in rectum

2nd degree = Prolapse through the anus on defecation but spontaneously reduce

3rd = Prolapse through the anus on defecation but require digital reduction

4th = Remain persistently prolapsed

Question 4

Risk factors

Answer 4

Excessive straining

Chronic constipation

Increasing age

Increased intraabdominal pressure (Pregnancy, chronic cough, ascites)

Pelvic or abdo masses

Cardiac failure

Portal HTN

Question 5

Clinical features

Answer 5

Painless bright red rectal bleeding

Pruritus

Rectal fullness

Anal lump

Soiling

Question 6

What if the haemorrhoid is painful?

Answer 6

Large prolapsed haemorrhoids can thrombose.

These are very painful and pateints frequently present acutely with them.

Question 7

Examination findings

Answer 7

Should be unremarkable unless prolapsed.

Thrombosed prolapsed haemorrhoid will present as purple/blue, oedematous, tense and tender perianal mass.

Question 8

Dx

Answer 8

Malignancy

IBD

Diverticular disease

Fissure-in-ano

Perianal abscess

Fistula in ano

Question 9

Investigations

Answer 9

Proctoscopy to confirm diagnosis if needed

FBC if there is prolonged bleeding or signs of anaemia

Coag screening

FLexible sigmoidoscopy or colonoscopy might be considered if to exclude malignancy

Question 10

General management

Answer 10

Usually conservative with lifestyle advice

Increasing daily fibres

Increase fluid intake

Prescribe laxatives if necessary

Topical lignocaine can be used

Reassurance

Question 11

Treatment of 1st and 2nd degree symptomatic haemorrhoids

Answer 11

Rubber-band ligation

Question 12

Explain RBL

Answer 12

Suction gun is applied and a rubber band placed over the neck of the haemorrhoid

Can be done in clinic or theatre

Question 13

Surgical interventions

Answer 13

Haemorrhoidal artery ligation (HAL)

Haemorrhoidectomy

Question 14

Explain HAL

Answer 14

2nd or 3rd degree haemorrhoids but usually not in 4th

Question 15

Explain haemorrhoidectomy

Answer 15

Not responding to conservative therapy and unsuitable for banding or injection.

Mainly done in 3rd and 4th degree via stapled haemorrhoidectomy or Milligan Morgan Haemorrhoidectomy

Question 16

Complications

Answer 16

Thrombosis

Ulceration

Gangrene

Skin tags

Perianal sepsis