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Hemorrhoids - Internal and External


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Hemorrhoids Dr. Angelo Smith M D WHPL

What Are Hemorrhoids?:

What Are Hemorrhoids? Alternative Names Rectal Lump Piles Lump in the Rectum Definition: Dilated or enlarged veins in the lower portion of the rectum or anus.


Frequency 10 million Peak ages: 45-65 years ½ of adults experience hemorrhoids by age 50 Common among pregnant women Temporary


ANATOMY AND CLASSIFICATION R ight anterior, Right posterior and Left lateral positions T hose originating above the dentate line which are termed internal T hose originating below the dentate line which are termed external

Internal Hemorrhoids:

Internal Hemorrhoids Internal Hemorrhoids Disease Manifested by two main symptoms - Painless Bleeding - Protrusion ( Pain is rare as they originate above dentate line ) Most popular etiologic theory states that Hemorrhoids result from chronic straining at defecation Continued straining causes engorgement and bleeding , as well as hemorrhoidal prolapse


Classification Grades: I- Hemorrhoids only bleed II- Prolapse and reduce spontaneously III- Require replacement IV- Permanently Prolapsed


Causes Pressure Constipation Diarrhea Sitting or standing for long periods of time Obesity Heavy Lifting Pregnancy


Symptoms Rectal Bleeding Bright red blood in stool Dripping in the toilet On wiping after defecation Pain during bowel movements Anal Itching Rectal Prolapse (while walking, lifting weights) Thrombus Extreme pain, bleeding and occasionally signs of systemic illness in case of strangulation

External Hemorrhoids:

External Hemorrhoids Asymptomatic except when secondary thrombosed Thrombosis may result from defecatory straining or extreme physical activity or may be random event Patient presents with constant anal pain of acute onset Physical examination identifies external thrombosis as purple mass at anal verge Management - Depends on patients symptoms - In the first 24 – 72 hours after onset, pain increase and excision is warranted - After 72 hours, pain generally diminishes

Signs and Tests:

Signs and Tests Rectal Examination Visual Digital Tests Stool Guaiac (FOBT) Sigmoidoscopy Anaoscopy Proctoscopy

Physical Examination:

Physical Examination Patients should be examined in the left lateral decubitus position (while asking the patient to bear down) any rashes, condylomata, or eczematous lesions. external sphincter function Any abscesses, fissures or fistulae

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lubricated finger should be gently inserted into the anal canal the resting tone of the anal canal should be ascertained as well as the voluntary contraction of the puborectalis and external anal sphincter. masses should be noted as well as any areas of tenderness.


Referral Gastroenterologists Seek emergency care if : large amounts of rectal bleeding Lightheadedness Weakness Rapid HR < 100 BPM


Complications The blood in the enlarged veins may form clots and the tissue surrounding the hemorrhoids can die (Necrosis) This causes painful lumps in the anal area. Severe bleeding can occur causing iron deficiency anemia.


Treatments Varies from simple reassurance to operative hemorrhoidectomy. Treatments are classified into three categories: 1) Dietary and lifestyle modification. 2) Non operative / office procedures. 3) Operative hemorrhoidectomy.

Dietary and Lifestyle Modifications:

Dietary and Lifestyle Modifications The main goal of this treatment is to minimize straining at stool. Achieved by increasing fluid and fiber in the diet, recommending exercise, and perhaps adding fiber agents to the diet such as psyllium. If necessary, stool softeners may be added. "you don't defecate in the library so you shouldn't read in the bathroom".

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Apply and OTC cream or suppository containing hydrocortisone Keep anal area clean Soak in a warm bath Apply ice packs or compresses x 10min

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If prolapses, gently push back into anal canal Use a sitz bath with warm water Use moist towelettes or wet toilet paper instead of dry toilet paper.


Office Treatments RUBBER BAND LIGATION Grade I or Grade II hemorrhoids and, in some circumstances, Grade III hemorrhoids. Complications include bleeding, pain, thrombosis and life threatening perianal sepsis. S uccessful in two thirds to three quarters of all individuals with first and second degree hemorrhoids.


Office Treatments INFRARED COAGULATION G enerates infrared radiation which coagulates tissue protein and evaporates water from cells. Most beneficial in Grade I and small Grade II hemorrhoids.

Office Treatments SCLEROTHERAPY:

Office Treatments SCLEROTHERAPY Injection of an irritating material into the sub mucosa in order to decrease vascularity and increase fibrosis. Injecting agents have traditionally been phenol in oil, sodium morrhuate, or quinine urea.

Office Treatments:

Office Treatments Manual anal dilatation was first described by Lord . Cryotherapy was used in the past with the belief that freezing the apex of the anal canal could result in decreased vascularity and fibrosis of the anal cushions.

Surgical Treatment of Hemorrhoids HEMORRHOIDECTOMY:

Surgical Treatment of Hemorrhoids HEMORRHOIDECTOMY The triangular shaped hemorrhoid is excised down to the underlying sphincter muscle. Wound can be closed or left open Stapled hemorrhoidectomy has been developed as an alternative to Standard hemorrhoidectomy


Prevention Eat high fiber diet Drink Plenty of Liquids Fiber Supplements Exercise Avoid long periods of standing or sitting Don’t Strain Go as soon as you feel the urge

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