Hemorrhoids

Background

1. most common cause of anal pathology
2. pt may present with mild symptoms (pruritis) or concerning symptoms (pain, bleeding)
3. 2 classifications:
   1. internal: above pectinate line (usuallypainless)
   2. external: below pectinate line (usually painful)
4. typically affects Caucasians from higher socioeconomic classes and rural areas, as well as pregnant females

Diagnosis

External

1. physical may reveal redundant tissue, skin tags from old thrombosed external hemorrhoids, fissures or fistulas, rectal or hemorrhoidal prolapse
2. Thrombosed hemorrhoids: painful mass at rectum that peaks at 48-72 hours and will start declining by day 4 as thrombus organizes
3. be aware of concominant anal fissure

Internal

1. Grade I: may protrude with defecation only
2. Grade II: prolapses and spontaneously reduces
3. Grade III: prolapses and requires manual reduction
4. Grade IV: prolapsed and unable to reduce

Work-Up

1. cbc to look at hemoglobin, wbc as marker for infection
2. anoscopy/proctoscopy

DDx

1. condyloma acuminata
2. proctitis
3. rectal prolapse
4. anal cancer, fissure, fistula
5. pedunculated polyp
6. perianal abscess
7. pruritis ani
8. colorectal tumor

Treatment

1. Nonsurgical
   1. Stool softener
   2. No straining
   3. Sitz baths x15min tid
   4. Steroid/Abx/Anusol cream
   5. increased fiber and fluid intake
   6. anal hygiene
   7. 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
2. Surgical
   1. Thrombosed external
      1. Excision (elliptical) is usually necessary only for severe pain
         1. Contraindications:
            1. >72 hours
            2. Crohn’s disease
            3. minimal pain
            4. uncooperative patient
            5. pregnant women
   2. Grade III/IV internal hemorrhoid
      1. surgical hemorrhoidectomy is best treatment

Source

Adapted from Donaldson