Hemorrhoids

• Internal hemorrhoid
• External hemorrhoid

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

Types

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

1. Usually self-limiting w/ resolution in 1 week
2. 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

See Also

• Anorectal Disorders

Source

Tintinalli