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| ==Background== | | ==Background== |
| *Occur when internal/external hemorrhoidal plexuses become engorged, prolapse, thrombosed
| | {{Hemorrhoid background}} |
| *Bleeding
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| **Usually limited (surface of stool, on toilet tissue, at end of defecation)
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| ***Passage of blood clots requires that colonic lesions are ruled-out
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| *Risk Factors
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| **Constipation and straining at stool
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| **Frequent diarrhea
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| **Older age
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| **IBD
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| ==Differential Diagnosis==
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| {{Anorectal DDX}} | |
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| ==Types== | | ==Types== |
| ===Internal===
| | [[File:M 44 anus 22.jpg|thumb|[[External hemorrhoid]]]] |
| *Occur proximal to dentate line
| | [[File:Perianal thrombosis 01.jpg|thumb|Thrombosed [[external hemorrhoid]]]] |
| *Constant in their location: 2-, 5-, and 9-o'clock positions (when pt viewed prone)
| | *[[Internal hemorrhoid]] |
| *Not readily palpable; best visualized through anoscope | | **Originate above the dentate line |
| **May be palpable when prolapsed or thrombosed | | **Painless |
| *Painless bleeding
| | *[[External hemorrhoid]] |
| **Only painful when nonreducible, prolapsed hemorrhoids strangulate OR thrombose
| | **Originate below the dentate line |
| ***Can lead to infection/necrosis
| | **Painful |
| *Prolapse
| | {{Internal Hemorrhoid Chart}} |
| **When prolapse occurs may develop mucous discharge and pruritus ani
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| ***If prolapse cannot be reduced progressive edema and strangulation may result
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| ***Other complications: severe bleeding, thrombosis, infarction, gangrene, sepsis
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| ====Classification====
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| *Grade I: Luminal protrusion above dentate line; no prolapse; painless bleeding
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| *Grade II: Prolapse with spontaneous reduction; prolapse during straining | |
| *Grade III: Prolapse requires manual reduction; prolapse during straining | |
| *Grade IV: Prolapse—nonreducible; can result in edema and strangulation | |
| ====Treatment====
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| #Conservative Tx
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| ##Indicated for mild to moderate symptomatic pts w/ grade 1 to grade 3 hemorrhoids
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| ##Stool softeners (psyllium), high-fiber diet, topical analgesics
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| ##Avoid laxatives causing liquid stool (can lead to cryptitis and anal sepsis)
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| ##Sitz bath 15min TID and after each bowel movement (decreases sphincter pressure)
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| ##Outpt surgical referral
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| ##Prolapsed hemorrhoid in pt w/ minimal symptoms can be manually reduced
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| #Emergent surgical consultation and intervention is indicated for:
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| ##Continued and severe bleeding
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| ##Incarceration and/or strangulation (grade 4 hemorrhoids)
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| ##Intractable pain
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| ===External===
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| *Occur distal to dentate line | |
| *Can be seen at external inspection
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| **More prominent with Valsalva | |
| *Thrombosed hemorrhoids (bluish-purple discoloration) cause painful defecation
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| **Non-thrombosed hemorrhoids are usually painless
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| ***If pt c/o pain but hemorrhoids are not thrombosed suspect:
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| ****Perianal/intersphincteric abscesses
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| ****Anal fissures
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| *Prolapse
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| **Requires periodic reduction by the pt
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| ====Treatment====
| | ==Treatment== |
| #Usually self-limiting w/ resolution in 1 week
| | *Increase fiber |
| #Thrombosed:
| | *Sitz baths |
| ##Consider sitz baths and bulk laxatives if:
| | *Topical steroid - Hydrocortizone |
| ###Thrombosis has been present >48 hr
| | *Topical anti-spasmodic - Nifedipine |
| ###Swelling has started to shrink
| | *See also treatment by specific type: |
| ###Pain is tolerable
| | **[[Internal hemorrhoid]] |
| ##Consider excision if:
| | **[[External hemorrhoid]] |
| ###Pt is not immunocompromised, child, pregnant woman, has portal HTN, coagulopathic
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| ###Thrombosis is acute (<48 hr)
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| ###Extremely painful
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| ###See [[External Hemorrhoid Excision]]
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| ==See Also== | | ==See Also== |
| *[[Anorectal Disorders]] | | *[[Anorectal disorders]] |
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| ==Source== | | ==References== |
| Tintinalli
| | <references/> |
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| [[Category:GI]] | | [[Category:GI]] |
