History

Fact Explanation
Anal discharge and itching [1] Because of difficulty with hygiene [1]
Painless rectal bleeding [2] Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement. The anal cushions of patients with hemorrhoids show significant pathological changes including venous dilatation.A severe inflammatory reaction involving the vascular wall and surrounding connective tissue causes mucosal ulceration.These changes leads to rectal bleeding [2]
Anal discomfort,sensation of a mass protruding out while defecation [1] External hemorrhoids can cause anal discomfort because of engorgement [1] Internal hemorrhoids are further graded based on their appearance and degree of prolapse. 1.First-degree: The anal cushions bleed but do not prolapse 2.Second-degree: The anal cushions prolapse through the anus on straining but reduce spontaneously 3.Third-degree: Anal cushions prolapse through the anus on straining and require manual replacement 4.Fourth-degree: Irreducible [2]
Acute pain [1] Thrombosis of external hemorrhoids can cause acute pain [1]
Constipation and prolonged straining [3] Widely believed to cause hemorrhoids because hard stool and increased intra abdominal pressure could cause obstruction of venous return, resulting in engorgement of the hemorrhoidal plexus (risk factors for hemorrhoids) [2]
Pregnancy, obesity [3] Risk factors for hemorrhoidal disease. Pregnancy can predispose to congestion of the anal cushion and symptomatic hemorrhoids, which will resolve spontaneously soon after birth [2]
Low fiber diet, less fluid intake [2] A low-fiber diet or inadequate fluid intake can cause constipation, which can contribute to hemorrhoids in two ways: It promotes straining during a bowel movement and it also aggravates the hemorrhoids by producing hard stools that further irritate the swollen veins [2]
References
  1. MOUNSEY AL, HALLADAY J, SADIQ TS. Hemorrhoids. Am Fam Physician [online] 2011 Jul 15, 84(2):204-10 [viewed 05 June 2014] Available from: http://www.aafp.org/afp/2011/0715/p204.html
  2. LOHSIRIWAT VARUT. Hemorrhoids: From basic pathophysiology to clinical management. WJG [online] 2012 December [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/
  3. FOXX-ORENSTEIN AE, UMAR SB, CROWELL MD. Common anorectal disorders. Gastroenterol Hepatol (N Y) [online] 2014 May, 10(5):294-301 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24987313

Examination

Fact Explanation
Perianal dermatitis and anal discharge [1] If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus [2]
Fistula-in-ano and anal fissures [2] Prolong constipation,which is a risk factor for hemorrhoids,can lead to anal fissures. [2]
Anal skin tags [2] A skin tag may remain after healing of an external hemorrhoid [2]
Digital rectal examination [1] Although internal hemorrhoids cannot be palpated, digital examination will detect abnormal anorectal mass, anal stenosis and scar, evaluate anal sphincter tone [2]
thrombosed external hemorrhoids [3] The thrombosed external hemorrhoids have a characteristic bluish color from the clot [3]
Abdominal examination- Intra abdominal masses [2] Increased intra abdominal pressure could cause obstruction of venous return, resulting in engorgement of the hemorrhoidal plexus [2]
References
  1. MOUNSEY AL, HALLADAY J, SADIQ TS. Hemorrhoids. Am Fam Physician [online] 2011 Jul 15, 84(2):204-10 [viewed 05 June 2014] Available from: http://www.aafp.org/afp/2011/0715/p204.html
  2. LOHSIRIWAT VARUT. Hemorrhoids: From basic pathophysiology to clinical management. WJG [online] 2012 December [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/
  3. HALVERSON AMY. Hemorrhoids. Clinics in Colon and Rectal Surgery [online] 2007 May, 20(2):077-085 [viewed 12 September 2014] Available from: doi:10.1055/s-2007-977485

Differential Diagnoses

Fact Explanation
Anal cancer [1] Pain around anus.Weight loss in advanced cases. On examination-Ulcerating lesion of anus [1]
Anal fissure [1] Painful rectal examination with fissure [1]
Colorectal cancer [1] Blood in stool, weight loss, abdominal pain, change in bowel habit, family history [1]
Inflammatory bowel disease [1] Constitutional symptoms, abdominal pain, diarrhea, family history [1]
References
  1. MOUNSEY AL, HALLADAY J, SADIQ TS. Hemorrhoids. Am Fam Physician [online] 2011 Jul 15, 84(2):204-10 [viewed 05 June 2014] Available from: http://www.aafp.org/afp/2011/0715/p204.html

Investigations - for Diagnosis

Fact Explanation
Anoscopy [1] Hemorrhoids are optimally visualized using an anoscope. [2] Internal hemorrhoids appear as dilated purplish-blue veins, and prolapsed internal hemorrhoids appear as dark pink, glistening, and sometimes tender masses at the anal margin,above the dentate line. External hemorrhoids appear below the dentate line,less pink and, if thrombosed, are acutely tender [1]
Proctoscopy [2] Proctoscopy may be performed in addition to anoscopy to evaluate the more proximal rectum [2]
References
  1. MOUNSEY AL, HALLADAY J, SADIQ TS. Hemorrhoids. Am Fam Physician [online] 2011 Jul 15, 84(2):204-10 [viewed 05 June 2014] Available from: http://www.aafp.org/afp/2011/0715/p204.html
  2. HALVERSON AMY. Hemorrhoids. Clinics in Colon and Rectal Surgery [online] 2007 May, 20(2):077-085 [viewed 12 September 2014] Available from: doi:10.1055/s-2007-977485

Investigations - Fitness for Management

Fact Explanation
Full blood count [1] Anemia- due to blood loss from hemorrhoids ( But anemia should not be attributed to hemorrhoids until the colon is adequately evaluated especially when the bleeding is atypical for hemorrhoids) [1]
References
  1. LOHSIRIWAT VARUT. Hemorrhoids: From basic pathophysiology to clinical management. WJG [online] 2012 December [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/

Investigations - Followup

Fact Explanation
History-Occurrence of recurrent prolapse [1] Recurrence of hemorrhoids after treatment [1]
Digital rectal examination [2] To check for recurrence after treatment [2]
References
  1. LUCARELLI P, PICCHIO M, CAPOROSSI M, DE ANGELIS F, DI FILIPPO A, STIPA F, SPAZIANI E. Transanal haemorrhoidal dearterialisation with mucopexy versus stapler haemorrhoidopexy: a randomised trial with long-term follow-up. Ann R Coll Surg Engl [online] 2013 May, 95(4):246-51 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23676807
  2. MICHALIK M, PAWLAK M, BOBOWICZ M, WITZLING M. Long-term outcomes of stapled hemorrhoidopexy. Wideochir Inne Tech Malo Inwazyjne [online] 2014 Mar, 9(1):18-23 [viewed 05 June 2014] Available from:http://www.ncbi.nlm.nih.gov/pubmed/24729805

Investigations - Screening/Staging

Fact Explanation
Anoscopy [1] Hemorrhoids are generally classified on the basis of their location and degree of prolapse [2] Internal hemorrhoids appear as dilated purplish-blue veins, and prolapsed internal hemorrhoids appear as dark pink, glistening, and sometimes tender masses at the anal margin. External hemorrhoids appear less pink and, if thrombosed, are acutely tender with a purplish [1]
History and rectal examination [2] Internal hemorrhoids are further graded based on their appearance and degree of prolapse. 1.First-degree: The anal cushions bleed but do not prolapse 2.Second-degree: The anal cushions prolapse through the anus on straining but reduce spontaneously 3.Third-degree: Anal cushions prolapse through the anus on straining and require manual replacement 4.Fourth-degree: Irreducible [2]
References
  1. MOUNSEY AL, HALLADAY J, SADIQ TS. Hemorrhoids. Am Fam Physician [online] 2011 Jul 15, 84(2):204-10 [viewed 05 June 2014] Available from: http://www.aafp.org/afp/2011/0715/p204.html
  2. LOHSIRIWAT VARUT. Hemorrhoids: From basic pathophysiology to clinical management. WJG [online] 2012 December [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/

Management - General Measures

Fact Explanation
Increasing intake of fiber [1] Trials of fiber show a consistent beneficial effect for symptoms and bleeding in the treatment of symptomatic hemorrhoids [1]
Abstaining from straining [2] May worsen the prolapse [2]
Increase water intake [2] To avoid constipation,which is a risk factor for hemorrhoids [2]
Improving anal hygiene [2] To control peri anal dermatitis [2]
Avoid straining [2] Straining can aggravate hemorrhoids [2]
Avoid medication that causes constipation [2] Constipation can aggravate hemorrhoids [2]
pain control [3] This can be done by conservative measures such as sitz baths and analgesia or surgical excision of the thrombosis, which is most effective during the first 48 to 72 hours after onset of symptoms [3]
References
  1. ALONSO-COELLO P, MILLS E, HEELS-ANSDELL D, LóPEZ-YARTO M, ZHOU Q, JOHANSON JF, GUYATT G. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol [online] 2006 Jan, 101(1):181-8 [viewed 05 June 2014] Available from:http://www.ncbi.nlm.nih.gov/pubmed/16405552/
  2. LOHSIRIWAT VARUT. Hemorrhoids: From basic pathophysiology to clinical management. WJG [online] 2012 December [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/
  3. FOXX-ORENSTEIN AE, UMAR SB, CROWELL MD. Common anorectal disorders. Gastroenterol Hepatol (N Y) [online] 2014 May, 10(5):294-301 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24987313

Management - Specific Treatments

Fact Explanation
Medical treatment -Oral flavonoids[1] These venotonic agents are used in the treatment of chronic venous insufficiency and edema. They are capable of increasing vascular tone, reducing venous capacity, decreasing capillary permeability, and facilitating lymphatic drainage as well as having anti-inflammatory effects [1]
Medical treatment - Topical treatment [1] Aims to control the symptoms rather than to cure the disease. Thus, other therapeutic treatments could be subsequently required.These contain local anesthesia, corticosteroids, antibiotics and anti-inflammatory drugs [1]
Non-operative treatment-Sclerotherapy [1] Currently recommended as a treatment option for first- and second-degree hemorrhoids. The rationale of injecting chemical agents is to create a fixation of mucosa to the underlying muscle by fibrosis.5% phenol in oil is used [1]
Non-operative treatment-Rubber band ligation [3] Recommended for first- and second-degree hemorrhoids and selected patients with third-degree hemorrhoids. Ligation of the hemorrhoidal tissue with a rubber band causes ischemic necrosis and scarring, leading to fixation of the connective tissue to the rectal wall [1] safe and reliable way for outpatient treatment of hemorrhoids [3] Efficient simple procedure for the second and third degree hemorrhoids with minimal complications [4]
Non-operative treatment- Infrared coagulation [8] photocoagulation therapy) is a non-surgical, medical procedure commonly used for Ist and IInd grade hemorrhoids and also in grade III cases which remain unfit for surgery [8] Produces infrared radiation which coagulates tissue and evaporizes water in the cell, causing shrinkage of the hemorrhoid mass [1]
Non-operative treatment-Radiofrequency ablation [1] By this method, vascular components of hemorrhoids are reduced and hemorrhoidal mass will be fixed to the underlying tissue by subsequent fibrosis [1]
Operative treatment-Hemorrhoidectomy [1] Operative methods are used for 3rd and 4th degree hemorrhoids. Although hemorrhoidectomy showed better response rates, it is associated with more complications and pain than rubber band ligation, thus should be reserved for those who fail to respond to rubber band ligation [2]
Operative treatment-Doppler-guided hemorrhoidal artery ligation [1] A new technique based on doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery [1] Doppler-guided arterial ligation seems to be effective after one year, with a low percentage of complications [5]
Operative treatment-Stapled hemorrhoidopexy [1] A circular stapling device is used to excise a ring of redundant rectal mucosa proximal to hemorrhoids and resuspend the hemorrhoids back within the anal canal. Apart from lifting the prolapsing hemorrhoids, blood supply to hemorrhoidal tissue is also interrupted [1] Long-term results of stapled hemorrhoidopexy are satisfactory in most patients. The recurrence rate correlates with the degree of hemorrhoidal prolapse before the operation, duration of the disease, female gender, and previous vaginal delivery [6] Stapled hemorrhoidopexy is associated with less post-operative pain and early resumption of activities of daily living [7]
References
  1. LOHSIRIWAT VARUT. Hemorrhoids: From basic pathophysiology to clinical management. WJG [online] 2012 December [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/
  2. MACRAE HM, MCLEOD RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum [online] 1995 Jul, 38(7):687-94 [viewed 05 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7607026
  3. MISAUNO MA, USMAN BD, NNADOZIE UU, OBIANO SK. Experience with rubber band ligation of hemorrhoids in northern Nigeria. Niger Med J [online] 2013 Jul, 54(4):258-60 [viewed 12 September 2014] Available from: doi:10.4103/0300-1652.119654
  4. LU LY, ZHU Y, SUN Q. A retrospective analysis of short and long term efficacy of RBL for hemorrhoids. Eur Rev Med Pharmacol Sci [online] 2013 Oct, 17(20):2827-30 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24174368
  5. GOMEZ-ROSADO JC, SANCHEZ-RAMIREZ M, CAPITAN-MORALES LC, VALDES-HERNANDEZ J, REYES-DIAZ ML, CINTAS-CATENA J, GUERRERO-GARCIA JM, GALAN-ALVAREZ J, OLIVA-MOMPEAN F. [One year follow-up after doppler-guided haemorrhoidal artery ligation]. Cir Esp [online] 2012 Oct, 90(8):513-7 [viewed 06 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/22525228
  6. MICHALIK M, PAWLAK M, BOBOWICZ M, WITZLING M. Long-term outcomes of stapled hemorrhoidopexy. Wideochir Inne Tech Malo Inwazyjne [online] 2014 Mar, 9(1):18-23 [viewed 06 June 2014] Available from:http://www.ncbi.nlm.nih.gov/pubmed/24729805
  7. JAISWAL SS, GUPTA D, DAVERA S. Stapled hemorrhoidopexy - Initial experience from a general surgery center. Med J Armed Forces India [online] 2013 Apr, 69(2):119-23 [viewed 12 September 2014] Available from: doi:10.1016/j.mjafi.2012.08.015
  8. SINGAL R, GUPTA S, DALAL AK, DALAL U, ATTRI AK. An optimal painless treatment for early hemorrhoids; our experience in Government Medical College and Hospital. J Med Life [online] 2013 Sep 15, 6(3):302-6 [viewed 12 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24146691