Anorectal Diseases
TAKE A GOOD HISTORY: Key questions:
Bowel movement quality, Anal pain (± with bowel movements), Bleeding, Prolapse/mass
HEMORRHOIDS (Gastroenterology 2004;126:1461-62 & 1463-73)
Symptomatic involvement of vascular cushions in the anal canal that contains veins/arteries, elastic/connective tissue, and smooth muscle
Thought to be from chronic straining at defecation and low-fiber diet
Increased colonic intraluminal pressure, submucosal and connective tissue support weakens with further enlargement of veins
As anal lining descends, the hemorrhoids are more exposed to pressure from straining and direct stool trauma
Results: stasis of blood, swelling, erosions, and subsequent bleeding
Predisposing conditions: pregnancy, constipation ± chronic straining, weight lifting
External: originate distal to dentate line of anus (the division between squamous epithelium distally and transitional columnar epithelium proximally), they are covered by squamous epithelium
Usually asymptomatic; Occasional swelling and discomfort with straining
Acute thrombosis: sudden onset of acute, persistent pain and a lump; Occasionally ulcerate with extruding clot
Treatment of thrombosed hemorrhoids:
Early (within a day or so): excision of the clot with the involved hemorrhoidal complex (as opposed to incision alone)
Late: bowel regime, oral analgesics, warm tub baths (most resolve within 3 weeks), alternative treatment includes topical 0.3% nifedipine applied BID (↓ tonicity of sphincter)
Internal: arise above the dentate line of anus, covered with transitional and columnar epithelium
Typically non-painful because they are above the anoderm without nerves; However pain occurs with incarceration
Degree of internal hemorrhoids
1st degree: swell and bleed
2nd degree: prolapse and spontaneously reduce
3rd degree: prolapse and can manually be reduced
4th degree: non-reducible
Treatment:Related posts:
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