Anorectal: Hemorrhoids

Hemorrhoids

Pathology

  • Definition: Enlarged Fibrovascular Cushions of the Anal Canal
  • Result from Straining & Venous Congestion
  • Causes:
    • Constipation or Diarrhea – Most Common
    • Pregnancy
    • COPD
    • Portal Hypertension
  • 3 Plexuses:
    • Right Anterior
    • Right Posterior
    • Left Lateral Mn

Hemorrhoids 1

Hemorrhoidal Plexuses 2

Classification

  • Internal Hemorrhoids
    • Proximal to Dentate Line
    • Overlying Anoderm (Columnar Epithelium & Visceral Nerves)
    • Grading: Based on Prolapse Below Dentate Line
      • I (Primary): Prolapse Only with Strain
      • II (Secondary): Spontaneously Reduce
      • III (Tertiary): Manually Reduce
      • IV (Quaternary): Cannot Reduce
  • External Hemorrhoids
    • Distal to Dentate Line
    • Overlying Skin (Squamous Epithelium & Somatic Nerves)
  • Mixed Hemorrhoids
    • Originate Both Above & Below the Dentate Line

Internal Hemorrhoids 3

External Hemorrhoids 4

Symptoms

  • Bleeding
    • Most Common Symptom of Internal Hemorrhoids: Painless Bleeding
    • Worse with Bowel Movements
    • Unlikely to Cause Significant Anemia
  • Pain if Thrombosed or Ulcerated
    • More Common in External Hemorrhoids
    • Thrombosis Naturally Resolves After 10-14 Days
      • Pain Resolves After 2-3 Days
  • Pruritis
  • Fecal Incontinence
  • Bulge
  • Mucus Discharge
  • Difficult Hygiene

Diagnosis

  • Physical Exam
    • “Starburst”/Radially Oriented Prolapse (Differentiates from Rectal Prolapse)
  • If Pain Preventing Adequate Physical Examination: Exam Under Anesthesia (EUA)
  • If Presenting for Bleeding and Source not Obvious: Endoscopy

Thrombosed Hemorrhoids 5

Hemorrhoids – Treatment

Management of Internal Hemorrhoids

  • Grade I/II: Medical
    • If Fails: Office-Based Procedure
      • Rubber Band Ligation
      • Sclerotherapy
      • Infrared Coagulation
    • If Fails Again: Hemorrhoidectomy
  • III: Office-Based Procedure or Hemorrhoidectomy
  • IV: Hemorrhoidectomy

Management of External Hemorrhoids

  • Initial: Medical
    • If Fails: Hemorrhoidectomy
  • If Acute Thrombosis:
    • < 72 Hours: Elliptical Excision/Enucleation
      • In Office If Tolerates
    • > 72 Hours: Lance
    • Already Resolving: Medical

Medical Managements

  • Fiber & Stool Softener
  • Sitz Baths
  • Increased Water Intake
  • Physical Activity
  • No Reading or Electronic Devices in Bathroom – Decrease Time Staining & Pressure from Squatting
  • OTC Hemorrhoidal Creams – No Proven Benefit
    • Prolonged Use Can Thin Perianal Skin & Exacerbate Symptoms

Surgical Management

Hemorrhoids in Pregnancy

  • Commonly Exacerbated During Pregnancy
  • Usually Resolve After Delivery
  • Tx: Medical (No Matter the Grade)
    • Surgery Can Trigger Preterm Labor
    • Only Indications for Hemorrhoidectomy: Strangulated or Gangrenous

Hemorrhoid Banding 6

Hemorrhoid Banding 7

Hemorrhoid Sclerotherapy 8

Hemorrhoid Infrared Coagulator 9

Hemorrhoidectomy 6

Mnemonics

Hemorrhoidal Plexuses

  • L-L: Left-Lateral
  • Right Has Anterior & Posterior

References

  1. Haggstrom M. Wikimedia Commons. (License: CC BY-SA-3.0)
  2. Lim SW. Aluminum potassium sulfate and tannic Acid injection for hemorrhoids. J Korean Soc Coloproctol. 2012 Apr;28(2):73-7. (License: CC BY-NC-3.0)
  3. Herold A. Wikimedia Commons. (License: CC BY-3.0)
  4. Pachacamac33. Wikimedia Commons. (License: Public Domain)
  5. Gunther KH. Wikimedia Commons. (License: CC BY-3.0)
  6. Bafford AC, Bleday R. UCSF Dept Surgery. (License: CC BY-3.0)
  7. Misauno MA, Usman BD, Nnadozie UU, Obiano SK. Experience with rubber band ligation of hemorrhoids in northern Nigeria. Niger Med J. 2013 Jul;54(4):258-60. (License: CC BY-NC-SA-3.0)
  8. Tomiki Y, Ono S, Aoki J, Takahashi R, Ishiyama S, Sugimoto K, Yaginuma Y, Kojima Y, Goto M, Okuzawa A, Sakamoto K. Treatment of Internal Hemorrhoids by Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and Tannic Acid. Diagn Ther Endosc. 2015;2015:517690. (License: CC BY-3.0)
  9. Singal R, Gupta S, Dalal AK, Dalal U, Attri AK. An optimal painless treatment for early hemorrhoids; our experience in Government Medical College and Hospital. J Med Life. 2013 Sep 15;6(3):302-6. (License: CC BY-2.0)