Hemorrhoids: Difference between revisions
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==Types==
==Types==
===Internal===
*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
*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
====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
====Treatment====
#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


===External===
===External===

Revision as of 12:27, 10 June 2015

Background

Template:Hemorroids background

Differential Diagnosis

Anorectal Disorders

Non-GI Look-a-Likes

Undifferentiated lower gastrointestinal bleeding

Types

External

  • Occur distal to dentate line
  • Can be seen at external inspection
    • More prominent with Valsalva
  • Thrombosed hemorrhoids (bluish-purple discoloration) cause painful defecation
    • Non-thrombosed hemorrhoids are usually painless
      • If pt c/o pain but hemorrhoids are not thrombosed suspect:
        • Perianal/intersphincteric abscesses
        • Anal fissures
  • Prolapse
    • Requires periodic reduction by the pt

Treatment

  1. Usually self-limiting w/ resolution in 1 week
  2. Thrombosed:
    1. Consider sitz baths and bulk laxatives if:
      1. Thrombosis has been present >48 hr
      2. Swelling has started to shrink
      3. Pain is tolerable
    2. Consider excision if:
      1. Pt is not immunocompromised, child, pregnant woman, has portal HTN, coagulopathic
      2. Thrombosis is acute (<48 hr)
      3. Extremely painful
      4. See External Hemorrhoid Excision

See Also

Source

Tintinalli

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