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Haemorrhoids (piles) (Differentials (Trauma Fissure, fistula, rectal…
Haemorrhoids (piles)
Differentials
Trauma
Fissure, fistula, rectal prolapse
Neoplastic
Colorectal cancer,
polyps, anal cancer
Infection
STI e.g. gonorrohea, syphilis, warts
Perianal abscess
Pruritus ani/threadworm
Degenerative
Diverticular disease
Vascular
Mesenteric ischemia
Autoimmune
IBD
Risk factors
High intra-abdominal pressure
Chronic cough
Pregnancy
Obesity/ascites
Heavy lifting/exercise
Age
Constipation
Straining
Diet
Low fibre
Family history
Connective tissue disorders
Complications
Infection
Sepsis/abscess
Skin changes
Ulceration
Skin tags
Bleeding
Perianal thrombosis
Ischemia/gangrene
Anaemia
Obstruction
Stenosis
Incarceration
Grading
(internal)
Grade 2
Protrude beyond the anal canal on straining
Spontaneously reduce when stop straining
Grade 3
Protrude outside the anal canal when relaxed
Reduce fully on manual pressure
Grade 1
Project into lumen of anal canal, no prolapse
Grade 4
Protrude outside the anal canal when relaxed
Cannot be manually reduced
Clinical
presentation
Perianal itching
PR bleeds
Perianal pain
PR mucous
Diagnosis
Examination
Abdo: nil
PR: visible piles (ask to strain), macerated skin,
skin tags, fissures/fistulas, fresh blood, hard stool
Investigations
Bloods
FBC (anaemia), G+S (large bleed)
Imaging
Proctoscope: internal haemorrhoids
Bedside
Obs
History
PC/HPC: pain/itching, PR bleeding,
rectal pain/discomfort, tenesmus, soiling
PMH: constipation
DH: causing constipation e.g. opiates, TCAs
FH: piles, other GI disease
SH: diet, smoking, alcohol
Pathophysiology
Pathology
When enlarged and symptomatic - piles
Types
Internal
Originate above dentate line
Columnar epithelium, no pain fibres
Not sensitive to touch/temp/pain (unless strangulated)
External
Originate below dentate line
Squamous epithelium (anoderm) is richly innervated
Therefore itchy and painful
Anatomy
Three vascular mucosal cushions in the anus
Cushions help maintain anal continence
Present at left lateral, right posterior, and right anterior
Dentate line 2cm from anal verge, demarks transition from
upper and lower anal canal
Epidemiology
Common 15-35%
Peak age 45-65y
Management
Initial A to E
Definitive
Medical
Laxatives/stool softeners
Analgesia (not opiates)
Surgery
Indication: 4th degree,
1/2/3 failed non-surgical
2) Stapled haemorrhoidoplexy
Stapled to relocate back into canal
1) Excisional haeorrhoidectomy
Surgical removal of haemorrhoids
3) Haemorrhoid artery ligation
Removes blood flow
Conservative
Referral to surgeons
Referral to 2 week wait pathway
High fibre diet
Weight loss
Non-surgical procedures
Indication: 1st degree failed
medical tx, 2/3 degree
1) Rubber band ligation
Cut off blood supply, ulcerates and falls off
2) Injection schlerotherapy
Cuts off blood supply, degenerates
Infrared/photocoagulation
Coagulates vessels with infrared light
Diathermy
Coagulates vessels with direct heat application
Definition
Abnormally swollen vascular mucosal cushions
that are present in the anal canal