Hemorrhoids
Background
- most common cause of anal pathology
- pt may present with mild symptoms (pruritis) or concerning symptoms (pain, bleeding)
- 2 classifications:
- internal: above pectinate line (usuallypainless)
- external: below pectinate line (usually painful)
- typically affects Caucasians from higher socioeconomic classes and rural areas, as well as pregnant females
Diagnosis
External:
- 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
- be aware of concominant anal fissure
Internal:
- Grade I: may protrude with defecation only
- Grade II: prolapses and spontaneously reduces
- Grade III: prolapses and requires manual reduction
- Grade IV: prolapsed and unable to reduce
Work-Up
- cbc to look at hemoglobin, wbc as marker for infection
- anoscopy/proctoscopy
DDx
- condyloma acuminata
- proctitis
- rectal prolapse
- anal cancer, fissure, fistula
- pedunculated polyp
- perianal abscess
- pruritis ani
- colorectal tumor
Treatment
- Nonsurgical
- Stool softener
- No straining
- Sitz baths x15min tid
- Steroid/Abx/Anusol cream
- increased fiber and fluid intake
- anal hygiene
- 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
- Surgical
- Thrombosed external
- Excision (elliptical) is usually necessary only for severe pain
- 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