Hemorrhoids

-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.

Treatment:

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.

Prognosis

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

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