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Anorectal: 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: 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 *See Anorectal: Hemorrhoidal Procedures 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 Haggstrom M