Internal hemorrhoid: Difference between revisions
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**Sitz bath 15min TID and after each bowel movement (decreases sphincter pressure) | **Sitz bath 15min TID and after each bowel movement (decreases sphincter pressure) | ||
**Outpt surgical referral | **Outpt surgical referral | ||
**Prolapsed hemorrhoid in patient | **Prolapsed hemorrhoid in patient with minimal symptoms can be manually reduced | ||
*Emergent surgical consultation and intervention is indicated for: | *Emergent surgical consultation and intervention is indicated for: | ||
**Continued and severe bleeding | **Continued and severe bleeding | ||
Revision as of 17:08, 11 July 2016
Background
Template: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
- 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 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)
- Outpt 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