Colon and Small Bowel—Hemorrhoids
Concept
Usually a presentation of pain or bleeding. Need to recog- nize the difference between internal and external hemor- rhoids. Know the various stages. Treatment is always initially conservative.
Way Question May be Asked?
“25 y/o male presents to your office with the complaint of a thrombosed hemorrhoid. It occurred about four days ago and hurts whenever he sits down or has a bowel move- ment.” May also present as rectal bleeding, acute throm- bosis, or incontinence.
How to Answer?
Again, don’t forget your basic H+P or it will turn out to be something other than hemorrhoids
History
Constipation Pain
Bleeding Topical therapy
History rectal complaints Family history IBD Prolapse history Incontinence
Physical Exam
Examine abdomen Rectal exam
Anoscopy (with pt in left lateral decub position!) Rigid sigmoidoscopy
May need to do exam under anesthesia
Look for malignancy, fistula, other rectal pathology (careful for scenario switch)
How to Answer
Stages of Internal hemorrhoids (above dentate line and therefore usually painless)
I Painless rectal bleeding
II Prolapse with defecation, spontaneously reduce III Same as II, but reduction only manually IV Unable to reduce
External hemorrhoids are below the dentate line and hurt when become thrombosed
Non-operative therapy (4–6 weeks) Bulk agents
Increasing water intake (6–8 glasses/day)
Topical agents (Tucks, Anusol HC, or Analpram) Sitz baths
Surgical Treatment
For acute thrombosis, bleeding thrombosis, thrombosis with superficial necrosis→ elliptical surgical excision under local anesthesia in your office
Stage I and II internal hemorrhoids→ rubber band lig- ation (make sure there is not significant external disease or any other benign anorectal disease)
Banding of only one or two quadrants
No banding if pt has any prostheses (heart valve, breast implant, pacemaker, joint replacement)
Stage III and IV and recurrent symptomatic external hemorrhoids treated with Ferguson closed hemorrhoidec- tomy (elliptical incision over each hemorrhoid down to sphincter and closure incorporating some of sphincter fibers to prevent prolapse)
Can also include lateral internal sphincterotomy
19 Part 1.qxd 10/19/05 2:51 AM Page 19
During operation:
Make sure to inject perineum, submucosa, and puden- dal nerves
Tape buttocks apart
Excise most symptomatic quadrant first
Excise minimal anoderm (remember risk of stenosis)
Common Curveballs
Anal carcinoma
Rectal prolapse rather than prolapsing hemorrhoid Anal fissure
Pt will have postoperative incontinence or anal stenosis Pt will have history of portal HTN or be on blood thin-
ners
Pt will be over age 40 (then need to r/o proximal disease with BE or colonoscopy before instituting therapy) Pt will develop postbanding bleeding or infection
Pt will have internal prostheses and desire hemorrhoidal banding
Pt will have inflammatory bowel disease (no hemor- rhoidectomy!)
Pt will be pregnant (manage nonoperatively)
Post-op urinary retention/bleeding/infection/pelvic sep- sis after closed hemorrhoidectomy
Strikeouts
Operating on thrombosed hemorrhoid after 48 hr Operating on Stage I or II internal hemorrhoids Not trying local measures first
Discussing new PPH therapy
Not being able to deal with complications of the proce- dure you choose
Operating on pt with IBD
Not recognizing other anorectal pathology (cancer)
20 Colon and Small Bowel—Hemorrhoids
Part 1.qxd 10/19/05 2:51 AM Page 20
