View source for Internal hemorrhoid

==Background==
{{Hemorroids background}}

==Clinical Features==
*Occur proximal to dentate line
*Constant in their location: 2-, 5-, and 9-o'clock positions (when patient viewed prone) 
*Not readily palpable; best visualized through anoscope
**May be palpable when prolapsed or thrombosed
*Painless bleeding
**Only painful when nonreducible, prolapsed hemorrhoids strangulate OR thrombose
***Can lead to infection/necrosis

==Differential Diagnosis==
{{Anorectal DDX}}

{{Lower GI bleeding DDX}}

==Evaluation==
===Classification===
*Grade I: Luminal protrusion above dentate line; no prolapse; painless bleeding
*Grade II: Prolapse with spontaneous reduction; prolapse during straining
*Grade III: Prolapse requires manual reduction; prolapse during straining
*Grade IV: Prolapse—nonreducible; can result in edema and strangulation

==Management==
*Conservative treatment
**Indicated for mild to moderate symptomatic patients with grade 1 to grade 3 hemorrhoids
**Stool softeners (psyllium), high-fiber diet, topical analgesics
**Avoid laxatives causing liquid stool (can lead to cryptitis and anal sepsis)
**Sitz bath 15min TID and after each bowel movement (decreases sphincter pressure)
**Outpatient surgical referral
**Prolapsed hemorrhoid in patient with minimal symptoms can be manually reduced
*Emergent surgical consultation and intervention is indicated for:
**Continued and severe bleeding
**Incarceration and/or strangulation (grade 4 hemorrhoids)
**Intractable pain 

===Prolapse===
*When prolapse occurs may develop mucous discharge and pruritus ani
**If prolapse cannot be reduced progressive edema and strangulation may result
**Other complications: severe bleeding, thrombosis, infarction, gangrene, sepsis

==Disposition==
*Usually outpatient

==See Also==
*[[Anorectal Disorders]]

==External Links==

==References==
<references/>

[[Category:GI]]