Hemorrhoids
· Symptomatic hemorrhoids result from dilatory distortion of vasculature and changes in connective tissue.
· Can present with bleeding, pruritus, fullness, discharge, burning, and pain
· Up to half of hemorrhoids visualized on anoscopy are not associated with symptoms
· 5% of the US suffer from symptomatic hemorrhoids.
· Risk factors include constipation, straining, frequent diarrhea, elderly, IBD.
· Internal Hemorrhoids
o Proximal to dentate line, covered in columnar epithelium, which DOES NOT have pain fibers.
o PAINLESS bleeding
o Best visualized through anoscope
o Goligher Classification
· Management
o Conservative treatment
§ Stool softeners (psyllium), topical analgesics
§ Sitz baths
§ Outpatient surgical referral
§ Prolapsed hemorrhoid in patient with minimal symptoms can be manually reduced
o Emergent surgical consult
§ Continued or severe bleeding
§ Incarcerated or strangulated (grade IV)
§ Intractable pain
External Hemorrhoids
Distal to dentate line, PAINFUL
Pain with defecation, bleeding
Color change, swelling, and or palpable clot suggest a thrombosed external hemorrhoid – tender on defecation, sitting, walking, or intercourse
Thrombosed external hemorrhoid.
Management
Not-thrombosed, usually self-limited and will resolve
Thrombosed
Conservative treatment (sitz baths and bulk laxatives) IF:
Thrombosis >72hrs
Swelling starting to shrink
Pain is tolerable
Conservative treatment can include topical 0.3% nifedipine and 1.5% viscous lidocaine
Perianal block for pain relief
Consider excision IF:
Patient is not immunocompromised, child, pregnant, portal hypertension, or coagulopathic
Thrombosis <72 hours (acute)
Extremely Painful
https://www.merckmanuals.com/professional/gastrointestinal-disorders/anorectal-disorders/hemorrhoids?query=external%20hemorrhoid (Instructional video)
Hemorrhoids - Gastrointestinal Disorders - Merck Manuals Professional Edition
www.merckmanuals.com
Hemorrhoids - Etiology, pathophysiology, symptoms, signs, diagnosis & prognosis from the Merck Manuals - Medical Professional Version.
Provide colorectal surgery follow up in 24-48 hours.
Anal Fissure
· Linear tear or ulceration of the anoderm that are visible on inspection
· May be due to passage of hard stool or frequent diarrhea.
· Most common cause of painful rectal bleeding
· Bright red rectal bleeding with SIGNIFICANT PAIN on defecation but can last several hours after
· Pain is thought to be due to hypertonic anal sphincter spam and resultant ischemia
· Waxing and waning course
· Primary (<8weeks) vs chronic (>8 weeks)
· 90% are midline posteriorly due to half the blood supply compared to other quadrants of anal canal
· Non-healing fissures or ones not located midline may suggest other etiology such as Crohn’s or malignancy
· Complications include anorectal abscess
· Management
o Warm sitz baths 15 mins TID-QID after each bowel movement
§ Provides symptomatic relief by improving anal blood flow and relieving anal spasm
o Topical medications
§ Lidocaine
§ Vasodilators such as nitroglycerin or nifedipine
§ Hydrocortisone
o Botulinum toxin can be used for treatment of chronic anal fissures, unfortunately it can also result in some form of temporary incontinence
o High-fiber diet
o Meticulous anal hygiene
o Surgical referral if healing does not occur in reasonable amount of time – Lateral internal sphincterotomy which is curative in 95% of patients, but 15% are left with some form of minor incontinence.
References:
https://accessemergencymedicine.mhmedical.com/content.aspx?sectionid=45343707&bookid=683#57707005
https://emottawablog.com/2019/10/the-bottom-line-hemorrhoids-and-anal-fissures-in-the-ed/
The Bottom Line: Hemorrhoids and Anal Fissures in the ED - EMOttawa Blog
https://www.mayoclinic.org/diseases-conditions/anal-fissure/symptoms-causes/syc-20351424