What Are Hemorrhoids?
§Lump in the Rectum
§Dilated or enlarged veins in the lower portion of the rectum or anus.
§Internal- Under the skin
§External- Around the anus
ANATOMY AND CLASSIFICATION-
§right anterior, right posterior and left lateral positions
§those originating above the dentate line which are termed internal
those originating below the dentate line which are termed external
§represent engorgement or enlargement of the normal fibrovascular cushions lining the anal canal.
§chronic straining secondary to constipation or occasionally diarrhea
§fibrovascular cushions lose their attachment to the underlying rectal wall.
§prolapse of internal hemorrhoidal tissue through the anal canal.
§the overlying mucosa becomes more friable and the vasculature increases.
§With overlying thinning of the mucosa and vascular engorgement, subsequent rectal bleeding occurs.
§classified by history and not by physical examination.
§Grade I - bleeding without prolapse.
§Grade II - prolapse with spontaneous reduction.
§Grade III - prolapse with manual reduction.
§Grade IV - incarcerated, irreducible prolapse.
§Peak ages: 45-65 years
§½ of adults experience hemorrhoids by age 50
§Common among pregnant women
§Bright red blood in stool
§Pain during bowel movements
§Sitting or standing for long periods of time
Signs and Tests-
§Stool Guaiac (FOBT)
§Patients should be examined in the left lateral decubitus position
§any rashes, condylomata, or eczematous lesions.
§external sphincter function
§Any abscesses, fissures or fistulae
§lubricated finger should be gently inserted into the anal canal while asking the patient to bear down
§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.
§internal hemorrhoids are generally not palpable on digital examination.
§anoscopy is performed.
§The side viewing anoscope should be inserted with the open portion in the right anterior then right posterior and finally the left lateral position
§Hemorrhoidal bundles will appear as bulging mucosa and anoderm within the open portion of the anoscope.
EVALUATION OF RECTAL BLEEDING-
§rule out rectal cancer.
§young individual with bleeding associated with hemorrhoidal disease and no other systemic symptoms, and no family history, perhaps anoscopy and rigid sigmoidoscopy
§older individual, with either a family history of colorectal cancer, or change in bowel habits, a complete colonoscopy should be performed to rule out proximal neoplasia.
§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 are classified into three categories:
1) Dietary and lifestyle modification.
2) Non operative/office procedures.
3) Operative hemorrhoidectomy.
§Mild cases are controlled by:
§Use of Fiber supplements
§Apply and OTC cream or suppository containing hydrocortisone
§Keep anal area clean
§Soak in a warm bath
§Apply ice packs or compresses x 10min
§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.
§For painful or persistant hemorrhoids:
§Tying off a hemorrhoid
§Alternative Name: Hemorrhoidectomy
§Hemorrhoid surgery is the removal of enlarged veins around the anus
§Reactions to medications of anesthesia
§Narrowing of the anus
*The outcome is usually very good in the majority of cases.
§Eat high fiber diet
§Drink Plenty of Liquids
§Avoid long periods of standing or sitting
Go as soon as you feel the urge