Diagnosis

Hemorrhoids

Etiology

Cause/Pathophysiology [gub]

• Pregnancy --> direct pressure --> decreased venous return

• Low-fibre diet --> constipation --> decreased venous return

• Portal hypertension --> decreased venous return

Risk factors [gub][ttg]

• Lack of erect posture

• Familial tendency

• Higher socioeconomic status

• Chronic diarrhea

• Colon malignancy

• Hepatic disease

• Obesity

• Elevated anal resting pressure

• Spinal cord injury

• Loss of rectal muscle tone

• Rectal surgery

• Episiotomy

• Anal intercourse

• Ulcerative colitis / Crohn disease

Classification of hemorrhoids [gub]

• Internal

• External

• Reducible

• Thrombosed

• Ischemic

Complications [ttg]

• Pain

• Bleeding

• Infection

Epidemiology

Incidence per 100.000 [q44][ngn][qqs]

Approach

• Blood test: Hb, PT-INR

• Rectal exam

• Anoscopy

• Rectoscopy

• Flexible sigmoidoscopy

• Colonoscopy

• Biopsy

Treatment

Only treat if symptoms. Asymptomatic hemorrhoids require no treatment.

1. Conservative treatment:

   • Diet: Increased fiber and liquid intake

   • Behaviour: Avoidance of straining and prolonged toilet sitting

   • Warm baths (twice or thrice daily)

2. Medical:

   • Stool softeners and antidiarrheal agents

   • Topical and systemic analgesics

   • Topical steroid cream

3. Surgery: [gub]

   • Internal hemorrhoids: No cutaneous innervation --> no anesthetic

     1. Rubber band ligation: recurrence rates of 30-50% within 5-10 years

     2. Ablation

     3. Sclerosis

     4. Hemorrhoidectomy: Grade III-IV or very symptomatic

   • External hemorrhoids (thrombosed):

     1. Hemorrhoidectomy:

        • Infiltration of a local anesthetic containing epinephrine

        • Elliptical incision and excision of the thrombosed hemorrhoid, its accompanying vein, and overlying skin

     2. Laser hemorrhoidectomy

     3. Stapled hemorrhoid surgery

     4. Doppler-guided transanal hemorrhoidal dearterialization

Differential diagnoses

Anal cancer, Anal fissure, Ascites, Cirrhosis, Colorectal cancer, Condyloma acuminatum, Constipation, Crohn disease, Portal hypertension, Pregnancy, Proctitis, Rectal prolapse, Ulcerative colitis