Internal hemorrhoid

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

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

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

1. 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
2. Emergent surgical consultation and intervention is indicated for:
   1. Continued and severe bleeding
   2. Incarceration and/or strangulation (grade 4 hemorrhoids)
   3. 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

See Also

• Anorectal Disorders