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Haemorrhoids

Maladywise

A quick summary of the Australian Doctor How To Treat Article on Haemorrhoids.

Summary

  • Only pathological if painful

  • Symptoms perianal itch, bleeding, lump

  • If severe pain consider fissure or abscess

  • Treatment is dietary changes, laxatives and behaviour modification

  • Thrombosed external haemorrhoids are common. Usually self-limiting.

  • Surgical options including haemorrhoidectomy, mucoplexy, staples and fricking lasers.

Indications for Referral

Internal

  • Low-grade pain and failed conservative treatment

  • Advanced and prolapsing

  • Those who require a colonoscopy

  • Diagnosis uncertain

External

  • Thrombosed external not responding conservative

  • Diagnosis uncertain

  • Residual anal tags

Medical Management

  • Dietary modification.

  • Adequate fluids and fibre intake.

  • Modification of daily bowel habit

  • Stool softeners

  • Paracetamol and Ibuprofen

  • Avoid straining.

  • Topical anaesthetics

  • Topical antispasmodic (Nifedipine 0.3% > GTN as lower risk headaches)

  • Sitz bath

  • Botox is an option

Background

  • Common. 50% of the population.

  • Symptoms vary.

  • Can mask colorectal cancer.

Pathophysiology

  • Abnormal swelling of cushions and stretching of connective tissue and muscle.

Risk Factors

  • Constipation. 

  • Chronic straining.

  • Passage of hard stool.

  • Increased abdominal pressure: chronic cough, pregnancy.

  • Prolonged sitting.

  • Hereditary.

  • Low fibre diet.

  • Decreased fluid intake.

Differential Diagnosis

Anal Fissure - Tearing pain, blood on paper or stool. May see on the exam, increased anal tone, pain+++

Rectal Prolapse - Obstructed defecation, incontinence

Rectal Polyp - Bleeding, tenesmus

Cancer - Blood mixed in stools, hard mass on PR

IBD - Blood and mucous, abdominal pain, family history

Perianal skin lesions - SCC risk factors, pruritus, bleeding

Colonoscopy Indicators

  • Age 50 or older if no colonoscopy within 10 years.

  • Age 40 or older or with a family history of colorectal cancer.

  • The pattern of bleeding or symptoms that are concerning for colon or rectal pathology.

Definition

  • Normal entity.

  • Fibrovascular cushions contribute 20% anal pressure and maintain continence.

  • The sensory nerve can discriminate solid, liquid and gas.

Symptoms

  • No correlation between symptoms and grade.

  • Bleeding

  • Sensation of swelling

  • Soiling

  • Itch

  • Pain

Diagnosis

  • Clinical

Red Flags

  • Change in bowel habit.

  • Change in weight/appetite.

  • Family history of malignancy or inflammatory bowel disease.

  • Abdominal pain.

  • Dark blood mixed with stools (colonic vs anorectal outlet bleeding).

  • Iron deficiency anaemia.

Surgical Treatment

  • Rubber band ligation

  • Superior to sclerotherapy and infra-red coat but less effective than a haemorrhoidectomy

  • Sclerotherapy

  • Infra-red Coag

  • Haemorrhoidectomy

Reference