PANCE Blueprint GI and Nutrition (10%)

Hemorrhoids (Lecture)

Patient with internal hemorrhoids will present as → a 43-year-old who has recently noticed bright red blood on the toilet paper when he wipes. He denies any fatigue, decreased exercise tolerance, abdominal pain, or maroon-colored or black, tarry stools. He has no family history of colon cancer. He has never had a colonoscopy. On physical exam, his temperature is 98.6 F, heart rate 70/min, and blood pressure 120/75 mmHg. He does not have conjunctival pallor. There are no abnormalities on cardiac, pulmonary, and abdominal exams.

Patients with external hemorrhoids will present with → significant pain, but no bleeding.

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    Internal hemorrhoids: no pain, but bright red blood per rectum

    • Internal hemorrhoids typically manifest with bleeding after defecation; blood is noted on toilet tissue and sometimes in the toilet bowl.
    • Internal hemorrhoids may be uncomfortable but are not as painful as thrombosed external hemorrhoids.
    • Internal hemorrhoids sometimes cause mucus discharge and a sensation of incomplete evacuation.

    External hemorrhoids (below dentate line): Pain, but no bleeding

    • External hemorrhoids may become thrombosed, resulting in a painful, purplish swelling. Rarely, they ulcerate and cause minor bleeding. Cleansing the anal region may be difficult.

    Strangulated hemorrhoids occur when protrusion and constriction occlude the blood supply. They cause pain that is occasionally followed by necrosis and ulceration.

    Anoscopy and sometimes sigmoidoscopy or colonoscopy

    • Most painful hemorrhoids, thrombosed, ulcerated or not, are seen on inspection of the anus and rectum.
    • Anoscopy is essential in evaluating painless or bleeding hemorrhoids.
    • Rectal bleeding should be attributed to hemorrhoids only after more serious conditions are excluded (ie, by sigmoidoscopy or colonoscopy).

    location of internal vs. external hemorrhoids

    Internal hemorrhoids: Stool softeners, sitz baths

    • Symptomatic treatment is usually all that is needed: stool softeners (eg, docusate, psyllium), warm sitz baths (ie, sitting in a tub of tolerably hot water for 10 min) after each bowel movement and as needed, anesthetic ointments containing lidocaine, or witch hazel (Hamamelis) compresses.
    • Bleeding internal hemorrhoids can be treated by injection sclerotherapy with 5% phenol in vegetable oil. Bleeding should cease at least temporarily.
    • Rubber band ligation is used for larger, prolapsing internal hemorrhoids or those that do not respond to conservative management.

    Occasionally excision for thrombosed external hemorrhoids

    • Pain caused by a thrombosed external hemorrhoid can be treated with NSAIDs.
    • Infrequently, simple excision of the external hemorrhoid is done, which may relieve pain rapidly; after infiltration with 1% lidocaine, the thrombosed portion of the hemorrhoid is excised, and the defect is closed with an absorbable suture.

    Question 1
    A 35-year-old man comes to your office with rectal bleeding, mucoid discharge from the rectum, and protrusion of certain structures through the anal canal. On proctoscopic examination, large internal hemorrhoids are seen. What is the best next step in the management of this patient?
    A
    proceed with definitive treatment
    B
    proceed with further investigations
    Hint:
    See A for answer
    C
    prescribe a hemorrhoidal cream
    Hint:
    See A for answer
    D
    do nothing; ask the patient to return in 6 months for review
    Hint:
    See A for answer
    Question 1 Explanation: 
    The next step in the management of this patient is to proceed with definitive treatment.
    Question 2
    What is the treatment of choice for this patient?
    A
    hemorrhoidal cream
    B
    hemorrhoidal ointment
    C
    rubber band ligation of the internal hemorrhoids
    D
    injection of phenol into the hemorrhoidal tissue
    Question 2 Explanation: 
    This patient has internal hemorrhoids. The treatment of choice for the protruding internal hemorrhoids that this patient has is rubber band ligation. Rubber band ligation is especially useful in situations in which the hemorrhoids are enlarged or prolapsing.
    Question 3
    A 56-year old woman came to the clinic complaining of a lump protruding from her anal opening. It was initially reducible, but it now irreducible. There is associated pain and itching. She also noticed bright-red blood on her stool when she defecates. There is an associated history of chronic constipation. Examination of the perianal area revealed skin tags and a tender perianal mass with covered with mucosa. Inspection of the anal mucosa showed no fissure. What is the most likely diagnosis?
    A
    Internal hemorrhoid
    B
    External hemorrhoid
    Hint:
    significant pain, but no bleeding.
    C
    Perianal hematoma
    Hint:
    Identified by the typical blue tinge under the surface of anal skin
    D
    Proctitis
    Hint:
    No perianal mass.
    Question 3 Explanation: 
    Hemorrhoids are symptomatic anal venous cushions. Symptoms of internal hemorrhoids include bright-red, painless bleeding, mucus discharge, prolapse, and pain only on prolapse.
    Question 4
    Concerning the patient above, what is the grade of the condition?
    A
    Grade I
    Hint:
    bleed only, no prolapse
    B
    Grade II
    Hint:
    prolapsed but reduces spontaneously
    C
    Grade III
    Hint:
    prolapsed and has to be manually reduced.
    D
    Grade IV
    Question 4 Explanation: 
    This is a Grade IV permanently prolapsed hemorrhoid
    Question 5
    Which of the following is the most appropriate treatment for the patient described above?
    A
    Sclerotherapy
    Hint:
    appropriate for grade I and II hemorrhoids when conservative measures fail.
    B
    Hemorrhoidectomy
    C
    Rubber band ligation
    Hint:
    appropriate for grade I and II hemorrhoids when conservative measures fail.
    D
    Conservative measures
    Hint:
    Conservative measures (High fiber diet, increased fluid intake, regular bowel opening) are used in managing grade I hemorrhoids.
    Question 5 Explanation: 
    Hemorrhoidectomy is the treatment of choice for grade IV hemorrhoids
    Question 6
    Complications of hemorrhoids include all of the following except
    A
    Ulceration
    Hint:
    See C for explanation
    B
    Portal pyemia
    Hint:
    Pyaemia (or pyemia) is a type of septicaemia that leads to widespread abscesses resulting from infected pyaemic thromb.
    C
    Rectal cancer
    D
    Anemia
    Hint:
    See C for explanation
    Question 6 Explanation: 
    Hemorrhoids do not lead to the development of rectal cancer. All other options are correct.
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