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  1. 1. Hemorrhoids Presentation Patients with external hemorrhoids generally complain of a painful purple lump covered with anal skin. It may have been precipitated by straining during defecation, heavy lifting, or pregnancy, but in most cases there was no definite preceding event. The external hemorrhoidal swelling is caused by thrombosis of the vein and is very tender to palpation and usually does not bleed unless there is erosion of the overlying skin. Patients with internal hemorrhoids usually seek help because of painless (or nearly painless) bright red bleeding at the time of defecation. Patients usually notice intermittant spotting on toilet tissue or episodic streaking of stool with blood. A prolapsed internal hemorrhoid appears as a protrusion of painless, moist red mass covered with rectal mucose at the anal verge. Prolapsed internal hemorrhoids may become strangulated and thrombosed, and thus painful. Itching is not a common symptom of hemorrhoids What to do: • If the problem is rectal bleeding, it should be approached as any other gastrointestinal bleeding. The amount of bleeding should be quantified with orthostatic vital signs and a hematocrit; the rectum should then be examined with an anoscope. For non-threatening rectal bleeding from hemorrhoids, the initial management should include a high fiber diet, stool softeners and bulk laxatives, and the patient should be instructed to spend less time sitting on the commode. Prolapsed or strangulated hemorrhoids warrant surgical consultation and possible hospital admission. All patients with rectal hemorrhage should be referred for a thorough gastroenterologic evaluation which might include proctosigmoidoscopy, barium enema or colonoscopy. Young patients in whom hemorrhoids are the obvious source of bleeding may not require more than a digital rectal examination and anoscopy. • If the problem is pain, the rectum should be examined using a topical anesthetic (lidocaine jelly) as a lubricant. First look for thrombosed external hemorrhoids and prolapsed internal hemorrhoids. Have the patient perform a Valsalva maneuver as you provide traction on the skin of the buttocks, to evert the anus. Examine the posterior mucosa for anal fissures. After the topical anesthesia has taken effect, complete the digital rectal exam, looking for internal hemorrhoids and evidence of rectal abscesses or other masses. • If topical mucosal anesthetic does not give enough relief to permit examination, follow with subcutaneous injection of 10mL of 1% lidocaine with epinephrine or bupivacaine for extended pain relief. • If topical anesthetics on the rectal mucosa help control the pain, provide for more of the same, perhaps also with some added corticosteroid for anti- inflammatory effect (Anusol-HC cream). Suppositories are convenient, but may not deliver the medication to where it is needed, so prescribe cream or foam (Proctofoam-HC, applied externally rather than internally).
  2. 2. • Instruct the patient to treat lesser pain and itching with witch hazel compresses, Tucks, and ice packs followed by warm sitz baths. Prevent constipation by using bulk laxatives (bran, psyllium) and stool softeners (docusate 50mg qd) and arrange follow up. Inform the patient that hemorrhoids may recur and require surgical removal. • Small ulcerated external hemorrhoids usually do not require any treatment for hemostasis. Bulk laxatives and gentle cleansing are generally all that is required. • If a thrombosed external hemorrhoid is still moderately to severely painful after topical anesthesia, apply an ice pack for 15 minutes and then inject around it with a local anesthetic to allow for examination and excision. The thrombus may be enucleated via an elliptical incision over the anal mucosa. Locular clots can be broken up by inserting a straight hemostat into the wound, and spreading the tips, thereby allowing the clots to be expressed. Pain relief from this simple surgical technique can be dramatic, but excision is not effective unless the entire thrombosed lesion is completely removed. Apply a compression dressing and tape the buttocks together for 12 hours to minimize bleeding. The patient can then begin the non-surgical treatment described above. Schedule a follow up examination in 2 days. Narcotics may be prescribed for a day, but should be switched to NSAIDs as soon as the risk of bleeding is less so they do not cause constipation. What not to do: • Do not labor to reduce prolapsed hemorrhoids unless they are part of a large rectal prolapse with some strangulation. Everything may prolapse again when the patient stands or strains. • Do not traumatize the patient with your examination. • Do not miss infectious and neoplastic processes which can resemble or coexist with hemorrhoids. • Do not excise a thrombosed hemorrhoid when the patient has a bleeding abmormality, is taking an anticoagulant or daily aspirin, or has increased portal venous pressure. Discussion The pathogenesis of hemorrhoids is multifactorial. Predisposing factors include heredity, portal hypertension, straining to defecate, and pregnancy. Internal hemorrhoids are classified into four groups. First-degree internal hemorrhoids do not protrude, cannot be palpated by digital examination, and require anoscopy for diagnosis. Second-degree hemorrhoids protrude with defecation, but reduce spontaneously. Third-degree hemorrhoids protrude and require manual reduction. Fourth-degree hemorrhoids are irreducibly prolapsed. Elastic banding techniques can be 80-90% curative for second, third and fourth degree internal hemorrhoids, but can increase prolapse of first-degree hemorrhoids. Patients with bleeding diatheses prolapse or both internal and external hemorrhoids are best treated by surgical resection. The diagnosis of "hemorrhoids" may cover a variety of minor ailments of the anus, which may or may not be related to the hemorrhoidal veins. The ED approach consists of ruling out immediately life-threatening problems, and then providing the patient with symptomatic relief and appropriate referral.
  3. 3. Hemorrhoidectomy for hemorrhoids Hemorrhoidectomy is surgery to remove hemorrhoids. You will be given general anesthesia or spinal anesthesia so that you will not feel pain. Incisions are made in the tissue around the hemorrhoid. The swollen vein inside the hemorrhoid is tied off to prevent bleeding, and the hemorrhoid is removed. The surgical area may be sewn closed or left open. Medicated gauze covers the wound. Surgery can be done with a knife (scalpel), a tool that uses electricity (cautery pencil), or a laser. The operation is usually done in a surgery center. You will most likely go home the same day (outpatient). There is a procedure that uses a circular stapling device to remove hemorrhoidal tissue and close the wound. No incision is made. In this procedure, the hemorrhoid is lifted and then "stapled" back into place in the anal canal. What to Expect After Surgery Recovery takes about 2 to 3 weeks. Going home after surgery Before the surgery, you will be given a long-acting local anesthetic. It should last 6 to 12 hours to provide pain relief after surgery. If you are not going to stay overnight in the hospital after surgery, you will leave only after the anesthesia wears off and you have urinated. Inability to urinate (urinary retention) sometimes occurs because of swelling (edema) in the tissues or a spasm of the pelvic muscles. This complication occurs in about 20% of people who have a hemorrhoidectomy. Someone should drive you home. Care after surgery You can expect some pain after surgery. If your doctor gave you a prescription medicine for pain, take it as prescribed. Ask your doctor what over-the-counter medicines are safe for you. Some bleeding is normal, especially with the first bowel movement after surgery.You may apply numbing medicines before and after bowel movements to relieve pain. Ice packs applied to the anal area may reduce swelling and pain. Frequent soaks in warm water (sitz baths) help relieve pain and muscle spasms. Some doctors may recommend that you take an antibiotic (such as metronidazole) after surgery to prevent infection and reduce pain. Health professionals recommend that you take stool softeners that contain fiber to help make your bowel movements smooth. Straining during bowel movements can cause hemorrhoids to come back. Follow-up exams with the surgeon usually are done 1 week and 3 weeks after surgery to check for problems. Why It Is Done Hemorrhoidectomy is appropriate when you have: Very large internal hemorrhoids. Internal hemorrhoids that still cause symptoms after nonsurgical treatment. Large external hemorrhoids that cause significant discomfort and make it difficult to keep the anal area clean. Both internal and external hemorrhoids. Had other treatments for hemorrhoids (such as rubber band ligation) that have failed. How Well It Works Hemorrhoids come back about 5% of the time after hemorrhoidectomy.1 Hemorrhoidectomy is done with equal success using traditional surgical tools and lasers.
  4. 4. Risks Pain, bleeding, and an inability to urinate (urinary retention) are the most common side effects of hemorrhoidectomy. Other relatively rare risks include the following: Early problems Bleeding from the anal area Collection of blood in the surgical area (hematoma) Inability to control the bowel or bladder (incontinence) Infection of the surgical area Stool trapped in the anal canal (fecal impaction) Late problems Narrowing (stenosis) of the anal canal Recurrence of hemorrhoids An abnormal passage (fistula) that forms between the anal or rectal canal and another area Rectal prolapse, which happens when the rectal lining slips out of the anal opening What to Think About The success of hemorrhoidectomy depends a lot on your ability to make changes in your daily bowel habits to make passing stools easier. Hemorrhoidectomy may provide better long-term results than procedures that cut off blood flow to hemorrhoids (fixative procedures). However, surgery is more costly, has a greater risk of complications, and usually is more painful. Most internal hemorrhoids improve (they get smaller and discomfort decreases) with either home treatment or fixative procedures. When compared with surgery, fixative procedures involve less risk, are less painful, and require less time away from work and other activities. Surgery is not recommended for small internal hemorrhoids (unless you also have large internal hemorrhoids or internal and external hemorrhoids). Lasers are often advertised as being a less painful, faster-healing method of removing hemorrhoids, but none of these claims have been proven. Lasers are more expensive than traditional techniques. The procedure takes longer, and it may cause deep tissue injury.