HEMORRHOIDS

 

 

Types:

  1. Internal hemorrhoids - located above pectinate line and drain into portal system. Portal system stasis may be responsible.
     
  2. External hemorrhoids - located below pectinate line. They drain into iliac system. Increase in abdominal pressure is responsible for its etiology.

Distinguishing features:

  1. Painless bleed seen with internal hemorrhoids.
     
  2. Painful  thrombosis consistent with external hemorrhoids.
     
  3. Prolapse seen with internal  lesions.

DX:

  1. External hemorrhoids are visible on inspection
     
  2. Internal hemorrhoids are visible only by anoscopic examination and are located at 2'-5'-9' o'clock positions
     
  3. When  thrombosed , external hemorrhoids appear as bluish, edematous, and  round spherical figures. Internal hemorrhoids have a  pinkish  hue.  Relation to dentate line is critical.

Treatment:

  • If no complications, treatment c/w:
    1. sitz bath x 15min TID and after each BM.
       
    2. stool softeners.
       
    3. preparation H and/or Anuso
      l
    4. Lidocaine jelly
       
  •  If thrombosis is present for > 48hrs  -  treat as above
  • If thrombosis is relatively  new <24 hr.:
    1. give pt Meperidine 50mg, infiltrate area with 1% Lidocaine + Epinephrine
       
    2. make elliptical incision over the thrombosed mass with blade # 11. Remove thrombus
       
    3. control the bleed with direct pressure and pressure dressing or gauze tacked in  x few hours
       
    4. pt is instructed to take first bath in 6-12 hr. and remove the dressing at that time.

Disposition:

    1. surgical referral is indicated for F/U. In ER if strangulation/gangrene or severe bleed are present, surgical consult is appropriate.

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