-If you feel you have hemorrhoids and need treatment, please visit Dr.Paul Kattupalli for a personal examination.

-Hemorrhoids are dilated submucosal vessels in the anus

-Hemorrhoids that originate above the dentate line are “internal” and those that originate below are “external.”

Internal hemorrhoids are arteriovenous communications between terminal branches of the superior rectal artery and rectal veins; they are covered with mucosa and transitional zone epithelium.

-External hemorrhoids arise from the inferior hemorrhoidal veins located below the dentate line; they are covered with squamous epithelium.

-Three main hemorrhoidal complexes traverse the anal canal—the left lateral, the right anterior, and the right posterior. Engorgement and straining lead to prolapse of this tissue into the anal canal.

-Hemorrhoids normally appear at 3 o’clock (when patients are in the lithotomy position), 7 o’clock, and 11 o’clock positions around the anus.

-Staging of hemorrhoids:

Stage I: Enlargement with bleeding

Stage II: Protrusion with spontaneous reduction

Stage III: Protrusion requiring manual reduction

Stage IV: Irreducible protrusion

Risk factors: Straining at stool, constipation, prolonged sitting, pregnancy, obesity, and low-fiber diets

Symptoms & Signs

Hemorrhoids are usually asymptomatic. Painless bright red blood seen either in the toilet or upon wiping when the blood vessel ruptures.Both internal and external hemorrhoids may develop a thrombosis, which causes significant pain.

External hemorrhoids:  mild pain, bright red rectal bleeding. Severe pain suggests thrombosis in the hemorrhoid.

Internal hemorrhoids: bleeding, fullness, discomfort, mucoid discharge,irritation of perianal skin, soiling of underclothes.

Diagnosis: Perianal inspection, anoscopy; Internal hemorrhoids are not readily palpable and can best be visualized through an anoscope. External hemorrhoids can be seen on external inspection.


Conservative measures: increase fluid intake with meal, eat a high-fiber diet, sitz baths, stool softeners

Medical Treatment: Injection sclerotherapy, rubber band ligation, or application of electrocoagulation (bipolar cautery or infrared photocoagulation), hydrocortisone, Preparation H, Anusol HC, Proctofoam.

Surgical Treatment: excisional hemorrhoidectomy, transhemorrhoidal dearterialization (THD), or stapled hemorrhoidectomy

Endoscopy: Older patients who have not had colorectal cancer screening should undergo colonoscopy or flexible sigmoidoscopy.


Although the most common cause of bright red rectal bleeding is hemorrhoids, tumors must be ruled out as a cause of rectal bleeding in patients >40 years of age.

  1. Majority of hemorrhoids are internal or external? Internal
  2. Why are uncomplicated internal hemorrhoids painless? due to visceral innervation and lack of sensory innervation.
  3. What do you consider in a patient with frequent diarrhea and hemorrhoids? Inflammatory bowel disease
  4. What is the most common cause of symptomatic hemorrhoids? Pregnancy
  5. What is the best means of definitive therapy for hemorrhoids? Hemorrhoidectomy

Q.What is the objective of sitz baths? to relax anal sphincter

Polyps of the colon

Colon cancer is the third most common cancer in the United States. If you want to schedule a colonoscopy with Dr.Paul Kattupalli, please call our office.

-Polyps are discrete mass lesions that are flat or protrude into the intestinal lumen. They arise from the epithelial cells lining the colon.

-Most commonly sporadic, may be inherited as part of familial polyposis syndrome

Of polyps removed at colonoscopy, over 70% are adenomatous; most of the remainder are serrated; distinguished by histology

-Of polyps removed at colonoscopy, over 70% are adenomatous

-Most colorectal cancers, regardless of etiology, arise from adenomatous polyps.

Four major pathological groups

  • Mucosal adenomatous polyps (tubular, tubulovillous, villous)
  • Mucosal serrated polyps (hyperplastic, sessile serrated polyp, traditional serrated adenoma)
  • Mucosal nonneoplastic polyps (juvenile polyps, hamartomas, inflammatory polyps)
  • Submucosal lesions (lipomas, lymphoid aggregates, carcinoids, pneumatosis cystoides intestinalis)

-Hyperplastic polyps located in the proximal colon (ie, proximal to the splenic flexure) may be associated with an increased risk of neoplasia, particularly those > 1 cm

Familial adenomatous polyposis of the colon is a rare autosomal dominant disorder associated with a deletion in the long arm of chromosome 5. Thousands of adenomatous polyps appear in the large colon, generally by age 25 years, and colorectal cancer develops in almost all these patients by age 40 years.

Peutz-Jeghers syndrome (PJS):It is an autosomal dominant syndrome characterized by multiple hamartomatous polyps in the gastrointestinal tract, mucocutaneous pigmentation, and an increased risk of gastrointestinal and non gastrointestinal cancer.

-Pigmentations occur on the lips and perioral region, palms of the hands, buccal mucosa, and soles of the feet.

-The most common sites of gastrointestinal tract malignancy are the colon and pancreas, and the most common site of extraintestinal tract cancer is the breast.


The most common genetic colon cancer syndrome is Lynch syndrome, formerly known as HNPCC.

– It is an autosomal dominant condition

Risk factors:

Older age: 85% in those older than age 60 years

Diet: Increased cholesterol is associated with a greater risk of polyps

Excess body weight

Inflammatory bowel disease

Alcohol consumption

Symptoms & Signs: Most patients with adenomatous and serrated polyps are completely asymptomatic. Chronic occult blood loss may lead to iron deficiency anemia. Large polyps may ulcerate, resulting in intermittent hematochezia


Laboratory Tests: Fecal occult blood test (FOBT), fecal immunochemical test (FIT), and fecal DNA tests

Imaging Studies:  CT colonography

Endoscopic tests: 1. Colonoscopy, which should be performed in all patients who have positive FOBT, FIT, or fecal DNA tests or iron deficiency anemia.

  1. Capsule endoscopy

Treatment: Colonoscopic polypectomy; periodic colonoscopic surveillance


-Chronic occult blood loss may lead to iron deficiency anemia.

-Untreated patients with polyps larger than 10 mm are at increased risk for colon cancer both at the site of the polyp and at other sites.

Q: What is the best means of detecting and removing adenomatous and serrated polyps? Colonoscopy

Q: FIT or FOBT: Which is more sensitive in the detection of colorectal cancer? FIT