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Questions and Answers
What is the main function of hemorrhoids in the anal canal?
What is the main presentation of anal fissure?
How many main vascular cushions are typically found in the anatomy of hemorrhoids?
Which factor is believed to be possibly related to the pathogenesis of anal fissure?
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Which factor does NOT contribute to the enlargement of hemorrhoids?
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What is a common complication following hemorrhoidectomy related to inadequate ligation of the pedicle?
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How are external hemorrhoids classified?
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How can urinary retention after hemorrhoidectomy be minimized?
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What is the primary factor responsible for weakening supporting connective tissue in aging individuals with hemorrhoids?
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What is a characteristic symptom of anal fissure?
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In internal hemorrhoids, where are the three main vascular cushions located?
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Which treatment is typically used for mild to moderate strictures in the context of stenosis/stricture treatment?
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Where are external hemorrhoids located?
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Which of the following is a characteristic of internal hemorrhoids?
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What is a possible consequence of thrombosis in external hemorrhoids?
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In which grade of internal hemorrhoids do they prolapse manually but are reducible?
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What does grade 4 internal hemorrhoids signify?
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What is the main indication for surgical therapy for hemorrhoids?
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Study Notes
Complications of Hemorrhoidectomy
- Post-operative pain can be managed with oral narcotics, NSAIDS, muscle relaxants, topical analgesics, and warm sitz baths.
- Massive bleeding can occur immediately due to inadequate ligation of the pedicle, requiring suture ligation.
- Urinary retention occurs in 10-50% of cases and can be minimized by limiting perioperative IV fluids and providing adequate analgesia.
Stenosis/Stricture
- Scarring after extensive resection of perianal skin can cause stenosis.
- Conservative management includes bowel habit training, bulk forming, and dilatation.
- Mild to moderate strictures can be treated with dilatation.
- Surgical options include stricture release, sphincterotomy, stricturoplasty, and anoplasty.
Anal Fissure
- Anal fissure is a tear in the anoderm distal to the dentate line, often related to trauma from hard stool or prolonged diarrhea.
- Essential features include linear ulcer in the lower half of the anal canal, usually in the posterior midline.
- Characteristic symptoms include tearing pain with defecation, hematochezia, and sensation of intense anal spasm.
- Primary fissure usually occurs in the posterior midline, while primary anterior midline fissure is common in females.
Treatment of Anal Fissure
- ALMORANAS: ask about patient history, signs and symptoms, and risk factors.
- Treatment options include medical therapy, botulinum toxin injection, and lateral internal sphincterotomy.
Hemorrhoidal Disease
- Hemorrhoids are cushions of specialized, highly vascular tissue found within the anal canal in the submucosal space.
- Everyone has hemorrhoids, but they become symptomatic when engorged or enlarged.
- Functions of hemorrhoids include contributing to anal continence and providing sensory information.
- Anatomy includes three main vascular cushions: left lateral, right anterolateral, and right posterolateral.
- Precipitating factors include elevated anal sphincter pressure, aging, and weakened supporting connective tissue.
Classification
- External hemorrhoids: distal 1/3 of anal canal, covered by anoderm, can bleed due to pressure necrosis.
- Internal hemorrhoids: proximal to dentate line, may prolapse or bleed, rarely painful unless thrombosis or necrosis occurs.
Classification of Internal Hemorrhoids
- Grade 1: may protrude into but do not prolapse out of anal canal, painless bleeding.
- Grade 2: prolapse on defecation, reduces spontaneously.
- Grade 3: prolapse, manually reducible, fecal leakage, pruritus ani.
- Grade 4: permanently prolapsed, irreducible.
Indications for Surgical Therapy
- Failure of medical and nonoperative therapy.
- Symptomatic grade III, grade IV, or mixed internal and external hemorrhoids.
- Bleeding from 1st and 2nd degree hemorrhoids improves with dietary fiber and stool softeners.
Complications of Internal Hemorrhoids
- Bleeding from 1st and 2nd degree hemorrhoids.
- Rubber band ligation can cause severe pain if banded distal to the dentate line.
- Urinary retention (1%) is more likely if the internal sphincter is inadvertently included.
- Infection may require debridement, drainage, and antibiotics.
- Bleeding may occur 7-10 days post RBL, usually self-limited.
Acute Thrombosed External Hemorrhoids
- Cause intense pain and a palpable perianal mass during the first 24-72 hours after thrombosis.
- Elliptical excision can be performed in the office under local anesthesia.
- Sitz baths and analgesics are often helpful after 72 hours.
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Description
Learn about the classification of internal and external hemorrhoids, including their characteristics, location, and symptoms. Understand the different grades of internal hemorrhoids and how they are categorized based on their presentation.
