Hemorrhoids: Difference between revisions

Revision as of 18:22, 2 August 2011

Background

Occur when internal/external hemorrhoidal plexuses become engorged, prolapse, thrombosed
Bleeding
- Usually limited (surface of stool, on toilet tissue, at end of defecation)
  - Passage of blood clots requires that colonic lesions are ruled-out
Risk Factors
- Constipation and straining at stool
- Frequent diarrhea
- Older age
- IBD

DDx

Condyloma acuminata
Proctitis
Rectal prolapse
Anal cancer, fissure, fistula
Pedunculated polyp
Perianal abscess
Pruritis ani
Colorectal tumor

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

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

Usually self-limiting w/ resolution in 1 week
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

Source

Tintinalli

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
-# most common cause of anal pathology
+*Occur when internal/external hemorrhoidal plexuses become engorged, prolapse, thrombosed
-# pt may present with mild symptoms (pruritis) or concerning symptoms (pain, bleeding)
+*Bleeding
-# 2 classifications:
+**Usually limited (surface of stool, on toilet tissue, at end of defecation)
-## internal: above pectinate line (usuallypainless)
+***Passage of blood clots requires that colonic lesions are ruled-out
-## external: below pectinate line (usually painful)
+*Risk Factors
-# typically affects Caucasians from higher socioeconomic classes and rural areas, as well as pregnant females
+**Constipation and straining at stool
+**Frequent diarrhea
-==Diagnosis==
+**Older age
-===External===
+**IBD
-# physical may reveal redundant tissue, skin tags from old thrombosed external hemorrhoids, fissures or fistulas, rectal or hemorrhoidal prolapse
-# Thrombosed hemorrhoids: painful mass at rectum that peaks at 48-72 hours and will start declining by day 4 as thrombus organizes
+==DDx==
-# be aware of concominant anal fissure
+#Condyloma acuminata
+#Proctitis
+#Rectal prolapse
+#Anal cancer, fissure, fistula
+#Pedunculated polyp
+#Perianal abscess
+#Pruritis ani
+#Colorectal tumor
+==Types==
 ===Internal===
-# Grade I: may protrude with defecation only
+*Occur proximal to dentate line
-# Grade II: prolapses and spontaneously reduces
+*Constant in their location: 2-, 5-, and 9-o'clock positions (when pt viewed prone)
-# Grade III: prolapses and requires manual reduction
+*Not readily palpable; best visualized through anoscope
-# Grade IV: prolapsed and unable to reduce
+**May be palpable when prolapsed or thrombosed
+*Painless bleeding
-==Work-Up==
+**Only painful when nonreducible, prolapsed hemorrhoids strangulate OR thrombose
-# cbc to look at hemoglobin, wbc as marker for infection
+***Can lead to infection/necrosis
-# anoscopy/proctoscopy
+*Prolapse
+**When prolapse occurs may develop mucous discharge and pruritus ani
-==DDx==
+***If prolapse cannot be reduced progressive edema and strangulation may result
-# condyloma acuminata
+***Other complications: severe bleeding, thrombosis, infarction, gangrene, sepsis
-# proctitis
+====Classification====
-# rectal prolapse
+*Grade I: Luminal protrusion above dentate line; no prolapse; painless bleeding
-# anal cancer, fissure, fistula
+*Grade II: Prolapse with spontaneous reduction; prolapse during straining
-# pedunculated polyp
+*Grade III: Prolapse requires manual reduction; prolapse during straining
-# perianal abscess
+*Grade IV: Prolapse—nonreducible; can result in edema and strangulation
-# pruritis ani
+====Treatment====
-# colorectal tumor
+#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===
+*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==
+====Treatment====
-# Nonsurgical
+#Usually self-limiting w/ resolution in 1 week
-## Stool softener
+#Thrombosed:
-## No straining
+##Consider sitz baths and bulk laxatives if:
-## Sitz baths x15min tid
+###Thrombosis has been present >48 hr
-## Steroid/Abx/Anusol cream
+###Swelling has started to shrink
-## increased fiber and fluid intake
+###Pain is tolerable
-## anal hygiene
+##Consider excision if:
-## if there is prolapse that you cannot manually reduce, try placing some sugar on the area of prolapse and see if it will reduce spontaneously
+###Pt is not immunocompromised, child, pregnant woman, has portal HTN, coagulopathic
-# Surgical
+###Thrombosis is acute (<48 hr)
-## Thrombosed external
+###Extremely painful
-### Excision (elliptical) is usually necessary only for severe pain
+###See [[External Hemorrhoid Excision]]
-#### Contraindications:
-##### >72 hours
-##### Crohn’s disease
-##### minimal pain
-##### uncooperative patient
-##### pregnant women
-## Grade III/IV internal hemorrhoid
-### surgical hemorrhoidectomy is best treatment
 ==Source==
-Adapted from Donaldson
+Tintinalli
 [[Category:GI]]