Internal hemorrhoid

Background

Anatomy of the anus.

Internal and external hemorrhoids divided by pectinate (dentate) line

• Pathologic state cccurs when internal or external hemorrhoid plexus become engorged, prolapsed, or thrombosed
• Bleeding is usually limited (surface of stool, on toilet tissue, at end of defecation)
  • Passage of blood clots requires evaluation for colon lesions

Risk Factors

• Constipation and straining at stool
• Frequent diarrhea
• Older age
• IBD

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, strangulation of prolapsed hemorrhoid, or thrombosis (these can lead to infection/necrosis)

Differential Diagnosis

Anorectal Disorders

• Anal fissure
• Anal fistula
• Anal malignancy
• Anal tags
• Anorectal abscess
• Coccydynia
• Colorectal malignancy
• Condyloma acuminata
• Constipation
• Crohn's disease
• Cryptitis
• GC/Chlamydia
• Fecal impaction
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Levator ani syndrome
• Pedunculated polyp
• Pilonidal cyst
• Proctalgia fugax
• Proctitis
• Pruritus ani
  • Enterobius (pinworms)
• Rectal foreign body
• Rectal prolapse
• Syphilitic fissure

Non-GI Look-a-Likes

• Prostatitis

Undifferentiated lower gastrointestinal bleeding

• Upper GI Bleeding
• Diverticular disease
  • Diverticulosis
  • Diverticulitis
• Vascular ectasia / angiodysplasia
• Inflammatory bowel disease
• Infectious colitis
• Mesenteric Ischemia / ischemic colitis
• Meckel's diverticulum
• Colorectal cancer / polyps
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Aortoenteric fistula
  • Nearly 100% mortality if untreated
  • Consider in patients with gastrointestinal bleeding and known abdominal aortic aneurysms or aortic grafts
• Rectal foreign body
• Rectal ulcer (HIV, Syphilis, STI)
• Anal fissure

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

• Generally may be discharged (unless need for surgical intervention)

See Also

• Anorectal Disorders