Hemorrhoids

Colorectal

Clinicals - History

Fact Explanation
Anal discharge and itching Because of difficulty with hygiene Anal discharge and itching
Because of difficulty with hygiene
Painless rectal bleeding Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement.
The anal cushions of patients with hemorrhoids show significant pathological changes including venous dilatation.A severe inflammatory reaction involving the vascular wall and surrounding connective tissue causes mucosal ulceration.These changes leads to rectal bleeding
Painless rectal bleeding
Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement.
The anal cushions of patients with hemorrhoids show significant pathological changes including venous dilatation.A severe inflammatory reaction involving the vascular wall and surrounding connective tissue causes mucosal ulceration.These changes leads to rectal bleeding
Anal discomfort,sensation of a mass protruding out while defecation External hemorrhoids can cause anal discomfort because of engorgement
Internal hemorrhoids are further graded based on their appearance and degree of prolapse.
1.First-degree: The anal cushions bleed but do not prolapse
2.Second-degree: The anal cushions prolapse through the anus on straining but reduce spontaneously
3.Third-degree: Anal cushions prolapse through the anus on straining and require manual replacement
4.Fourth-degree: Irreducible
Anal discomfort,sensation of a mass protruding out while defecation
External hemorrhoids can cause anal discomfort because of engorgement
Internal hemorrhoids are further graded based on their appearance and degree of prolapse.
1.First-degree: The anal cushions bleed but do not prolapse
2.Second-degree: The anal cushions prolapse through the anus on straining but reduce spontaneously
3.Third-degree: Anal cushions prolapse through the anus on straining and require manual replacement
4.Fourth-degree: Irreducible
Acute pain Thrombosis of external hemorrhoids can cause acute pain Acute pain
Thrombosis of external hemorrhoids can cause acute pain
Constipation and prolonged straining Widely believed to cause hemorrhoids because hard stool and increased intra abdominal pressure could cause obstruction of venous return, resulting in engorgement of the hemorrhoidal plexus (risk factors for hemorrhoids) Constipation and prolonged straining
Widely believed to cause hemorrhoids because hard stool and increased intra abdominal pressure could cause obstruction of venous return, resulting in engorgement of the hemorrhoidal plexus (risk factors for hemorrhoids)
Pregnancy, obesity Risk factors for hemorrhoidal disease. Pregnancy can predispose to congestion of the anal cushion and symptomatic hemorrhoids, which will resolve spontaneously soon after birth Pregnancy, obesity
Risk factors for hemorrhoidal disease. Pregnancy can predispose to congestion of the anal cushion and symptomatic hemorrhoids, which will resolve spontaneously soon after birth
Low fiber diet, less fluid intake A low-fiber diet or inadequate fluid intake can cause constipation, which can contribute to hemorrhoids in two ways: It promotes straining during a bowel movement and it also aggravates the hemorrhoids by producing hard stools that further irritate the swollen veins Low fiber diet, less fluid intake
A low-fiber diet or inadequate fluid intake can cause constipation, which can contribute to hemorrhoids in two ways: It promotes straining during a bowel movement and it also aggravates the hemorrhoids by producing hard stools that further irritate the swollen veins

Clinicals - Examination

Fact Explanation
Perianal dermatitis and anal discharge If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus Perianal dermatitis and anal discharge
If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus
Fistula-in-ano and anal fissures Prolong constipation,which is a risk factor for hemorrhoids,can lead to anal fissures. Fistula-in-ano and anal fissures
Prolong constipation,which is a risk factor for hemorrhoids,can lead to anal fissures.
Anal skin tags A skin tag may remain after healing of an external hemorrhoid Anal skin tags
A skin tag may remain after healing of an external hemorrhoid
Digital rectal examination Although internal hemorrhoids cannot be palpated, digital examination will detect abnormal anorectal mass, anal stenosis and scar, evaluate anal sphincter tone Digital rectal examination
Although internal hemorrhoids cannot be palpated, digital examination will detect abnormal anorectal mass, anal stenosis and scar, evaluate anal sphincter tone
thrombosed external hemorrhoids The thrombosed external hemorrhoids have a characteristic bluish color from the clot thrombosed external hemorrhoids
The thrombosed external hemorrhoids have a characteristic bluish color from the clot
Abdominal examination- Intra abdominal masses Increased intra abdominal pressure could cause obstruction of venous return, resulting in engorgement of the hemorrhoidal plexus Abdominal examination- Intra abdominal masses
Increased intra abdominal pressure could cause obstruction of venous return, resulting in engorgement of the hemorrhoidal plexus

Investigations - Diagnosis

Fact Explanation
Anoscopy Hemorrhoids are optimally visualized using an anoscope.
Internal hemorrhoids appear as dilated purplish-blue veins, and prolapsed internal hemorrhoids appear as dark pink, glistening, and sometimes tender masses at the anal margin,above the dentate line. External hemorrhoids appear below the dentate line,less pink and, if thrombosed, are acutely tender
Anoscopy
Hemorrhoids are optimally visualized using an anoscope.
Internal hemorrhoids appear as dilated purplish-blue veins, and prolapsed internal hemorrhoids appear as dark pink, glistening, and sometimes tender masses at the anal margin,above the dentate line. External hemorrhoids appear below the dentate line,less pink and, if thrombosed, are acutely tender
Proctoscopy Proctoscopy may be performed in addition to anoscopy to evaluate the more proximal rectum Proctoscopy
Proctoscopy may be performed in addition to anoscopy to evaluate the more proximal rectum

Investigations - Management

Fact Explanation
History-Occurrence of recurrent prolapse Recurrence of hemorrhoids after treatment History-Occurrence of recurrent prolapse
Recurrence of hemorrhoids after treatment
Digital rectal examination To check for recurrence after treatment Digital rectal examination
To check for recurrence after treatment
Full blood count Anemia- due to blood loss from hemorrhoids ( But anemia should not be attributed to hemorrhoids until the colon is adequately evaluated especially when the bleeding is atypical for hemorrhoids) Full blood count
Anemia- due to blood loss from hemorrhoids ( But anemia should not be attributed to hemorrhoids until the colon is adequately evaluated especially when the bleeding is atypical for hemorrhoids)
Anoscopy Hemorrhoids are generally classified on the basis of their location and degree of prolapse
Internal hemorrhoids appear as dilated purplish-blue veins, and prolapsed internal hemorrhoids appear as dark pink, glistening, and sometimes tender masses at the anal margin. External hemorrhoids appear less pink and, if thrombosed, are acutely tender with a purplish
Anoscopy
Hemorrhoids are generally classified on the basis of their location and degree of prolapse
Internal hemorrhoids appear as dilated purplish-blue veins, and prolapsed internal hemorrhoids appear as dark pink, glistening, and sometimes tender masses at the anal margin. External hemorrhoids appear less pink and, if thrombosed, are acutely tender with a purplish
History and rectal examination Internal hemorrhoids are further graded based on their appearance and degree of prolapse.
1.First-degree: The anal cushions bleed but do not prolapse
2.Second-degree: The anal cushions prolapse through the anus on straining but reduce spontaneously
3.Third-degree: Anal cushions prolapse through the anus on straining and require manual replacement
4.Fourth-degree: Irreducible
History and rectal examination
Internal hemorrhoids are further graded based on their appearance and degree of prolapse.
1.First-degree: The anal cushions bleed but do not prolapse
2.Second-degree: The anal cushions prolapse through the anus on straining but reduce spontaneously
3.Third-degree: Anal cushions prolapse through the anus on straining and require manual replacement
4.Fourth-degree: Irreducible

Management - Supportive

Fact Explanation
Increasing intake of fiber Trials of fiber show a consistent beneficial effect for symptoms and bleeding in the treatment of symptomatic hemorrhoids Increasing intake of fiber
Trials of fiber show a consistent beneficial effect for symptoms and bleeding in the treatment of symptomatic hemorrhoids
Abstaining from straining May worsen the prolapse Abstaining from straining
May worsen the prolapse
Increase water intake To avoid constipation,which is a risk factor for hemorrhoids Increase water intake
To avoid constipation,which is a risk factor for hemorrhoids
Improving anal hygiene To control peri anal dermatitis Improving anal hygiene
To control peri anal dermatitis
Avoid straining Straining can aggravate hemorrhoids Avoid straining
Straining can aggravate hemorrhoids
Avoid medication that causes constipation Constipation can aggravate hemorrhoids Avoid medication that causes constipation
Constipation can aggravate hemorrhoids
pain control This can be done by conservative measures such as sitz baths and analgesia or surgical excision of the thrombosis, which is most effective during the first 48 to 72 hours after onset of symptoms pain control
This can be done by conservative measures such as sitz baths and analgesia or surgical excision of the thrombosis, which is most effective during the first 48 to 72 hours after onset of symptoms

Management - Specific

Fact Explanation
Medical treatment -Oral flavonoids These venotonic agents are used in the treatment of chronic venous insufficiency and edema. They are capable of increasing vascular tone, reducing venous capacity, decreasing capillary permeability, and facilitating lymphatic drainage as well as having anti-inflammatory effects Medical treatment -Oral flavonoids
These venotonic agents are used in the treatment of chronic venous insufficiency and edema. They are capable of increasing vascular tone, reducing venous capacity, decreasing capillary permeability, and facilitating lymphatic drainage as well as having anti-inflammatory effects
Medical treatment - Topical treatment Aims to control the symptoms rather than to cure the disease. Thus, other therapeutic treatments could be subsequently required.These contain local anesthesia, corticosteroids, antibiotics and anti-inflammatory drugs Medical treatment - Topical treatment
Aims to control the symptoms rather than to cure the disease. Thus, other therapeutic treatments could be subsequently required.These contain local anesthesia, corticosteroids, antibiotics and anti-inflammatory drugs
Non-operative treatment-Sclerotherapy Currently recommended as a treatment option for first- and second-degree hemorrhoids. The rationale of injecting chemical agents is to create a fixation of mucosa to the underlying muscle by fibrosis.5% phenol in oil is used Non-operative treatment-Sclerotherapy
Currently recommended as a treatment option for first- and second-degree hemorrhoids. The rationale of injecting chemical agents is to create a fixation of mucosa to the underlying muscle by fibrosis.5% phenol in oil is used
Non-operative treatment-Rubber band ligation Recommended for first- and second-degree hemorrhoids and selected patients with third-degree hemorrhoids. Ligation of the hemorrhoidal tissue with a rubber band causes ischemic necrosis and scarring, leading to fixation of the connective tissue to the rectal wall
safe and reliable way for outpatient treatment of hemorrhoids
Efficient simple procedure for the second and third degree hemorrhoids with minimal complications
Non-operative treatment-Rubber band ligation
Recommended for first- and second-degree hemorrhoids and selected patients with third-degree hemorrhoids. Ligation of the hemorrhoidal tissue with a rubber band causes ischemic necrosis and scarring, leading to fixation of the connective tissue to the rectal wall
safe and reliable way for outpatient treatment of hemorrhoids
Efficient simple procedure for the second and third degree hemorrhoids with minimal complications
Non-operative treatment- Infrared coagulation photocoagulation therapy) is a non-surgical, medical procedure commonly used for Ist and IInd grade hemorrhoids and also in grade III cases which remain unfit for surgery
Produces infrared radiation which coagulates tissue and evaporizes water in the cell, causing shrinkage of the hemorrhoid mass
Non-operative treatment- Infrared coagulation
photocoagulation therapy) is a non-surgical, medical procedure commonly used for Ist and IInd grade hemorrhoids and also in grade III cases which remain unfit for surgery
Produces infrared radiation which coagulates tissue and evaporizes water in the cell, causing shrinkage of the hemorrhoid mass
Non-operative treatment-Radiofrequency ablation By this method, vascular components of hemorrhoids are reduced and hemorrhoidal mass will be fixed to the underlying tissue by subsequent fibrosis Non-operative treatment-Radiofrequency ablation
By this method, vascular components of hemorrhoids are reduced and hemorrhoidal mass will be fixed to the underlying tissue by subsequent fibrosis
Operative treatment-Hemorrhoidectomy Operative methods are used for 3rd and 4th degree hemorrhoids.
Although hemorrhoidectomy showed better response rates, it is associated with more complications and pain than rubber band ligation, thus should be reserved for those who fail to respond to rubber band ligation
Operative treatment-Hemorrhoidectomy
Operative methods are used for 3rd and 4th degree hemorrhoids.
Although hemorrhoidectomy showed better response rates, it is associated with more complications and pain than rubber band ligation, thus should be reserved for those who fail to respond to rubber band ligation
Operative treatment-Doppler-guided hemorrhoidal artery ligation A new technique based on doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery
Doppler-guided arterial ligation seems to be effective after one year, with a low percentage of complications
Operative treatment-Doppler-guided hemorrhoidal artery ligation
A new technique based on doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery
Doppler-guided arterial ligation seems to be effective after one year, with a low percentage of complications
Operative treatment-Stapled hemorrhoidopexy A circular stapling device is used to excise a ring of redundant rectal mucosa proximal to hemorrhoids and resuspend the hemorrhoids back within the anal canal. Apart from lifting the prolapsing hemorrhoids, blood supply to hemorrhoidal tissue is also interrupted
Long-term results of stapled hemorrhoidopexy are satisfactory in most patients. The recurrence rate correlates with the degree of hemorrhoidal prolapse before the operation, duration of the disease, female gender, and previous vaginal delivery
Stapled hemorrhoidopexy is associated with less post-operative pain and early resumption of activities of daily living
Operative treatment-Stapled hemorrhoidopexy
A circular stapling device is used to excise a ring of redundant rectal mucosa proximal to hemorrhoids and resuspend the hemorrhoids back within the anal canal. Apart from lifting the prolapsing hemorrhoids, blood supply to hemorrhoidal tissue is also interrupted
Long-term results of stapled hemorrhoidopexy are satisfactory in most patients. The recurrence rate correlates with the degree of hemorrhoidal prolapse before the operation, duration of the disease, female gender, and previous vaginal delivery
Stapled hemorrhoidopexy is associated with less post-operative pain and early resumption of activities of daily living

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