Internal hemorrhoid: Difference between revisions
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==Background== | ==Background== | ||
{{Hemorroids background}} | {{Hemorroids background}} | ||
==Clinical Features== | ==Clinical Features== | ||
*Occur proximal to dentate line | *Occur proximal to dentate line | ||
*Constant in their location: 2-, 5-, and 9-o'clock positions (when pt viewed prone) | *Constant in their location: 2-, 5-, and 9-o'clock positions (when pt viewed prone) | ||
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**Only painful when nonreducible, prolapsed hemorrhoids strangulate OR thrombose | **Only painful when nonreducible, prolapsed hemorrhoids strangulate OR thrombose | ||
***Can lead to infection/necrosis | ***Can lead to infection/necrosis | ||
==Differential Diagnosis== | |||
{{Anorectal DDX}} | |||
====Classification | {{Lower GI bleeding DDX}} | ||
==Diagnosis== | |||
===Classification=== | |||
*Grade I: Luminal protrusion above dentate line; no prolapse; painless bleeding | *Grade I: Luminal protrusion above dentate line; no prolapse; painless bleeding | ||
*Grade II: Prolapse with spontaneous reduction; prolapse during straining | *Grade II: Prolapse with spontaneous reduction; prolapse during straining | ||
*Grade III: Prolapse requires manual reduction; prolapse during straining | *Grade III: Prolapse requires manual reduction; prolapse during straining | ||
*Grade IV: Prolapse—nonreducible; can result in edema and strangulation | *Grade IV: Prolapse—nonreducible; can result in edema and strangulation | ||
== | |||
==Management== | |||
#Conservative Tx | #Conservative Tx | ||
##Indicated for mild to moderate symptomatic pts w/ grade 1 to grade 3 hemorrhoids | ##Indicated for mild to moderate symptomatic pts w/ grade 1 to grade 3 hemorrhoids | ||
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##Incarceration and/or strangulation (grade 4 hemorrhoids) | ##Incarceration and/or strangulation (grade 4 hemorrhoids) | ||
##Intractable pain | ##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== | |||
==See Also== | ==See Also== | ||
*[[Anorectal Disorders]] | |||
==External Links== | |||
==References== | |||
<references/> | |||
[[Category:GI]] | [[Category:GI]] | ||
Revision as of 12:20, 10 June 2015
Background
Template:Hemorroids background
Clinical Features
- Occur proximal to dentate line
- Constant in their location: 2-, 5-, and 9-o'clock positions (when pt 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
- Only painful when nonreducible, prolapsed hemorrhoids strangulate OR thrombose
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
- 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
Undifferentiated lower gastrointestinal bleeding
- Upper GI Bleeding
- Diverticular disease
- Vascular ectasia / angiodysplasia
- Inflammatory bowel disease
- Infectious colitis
- Mesenteric Ischemia / ischemic colitis
- Meckel's diverticulum
- Colorectal cancer / polyps
- Hemorrhoids
- 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
Diagnosis
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 Tx
- Indicated for mild to moderate symptomatic pts w/ 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)
- Outpt surgical referral
- Prolapsed hemorrhoid in pt w/ 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