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Case 048: Hemorrhoids.

Author: David C Chung MD, FRCPC Affiliation: The Chinese University of Hong Kong

Mr. RCR was a 43 year old accountant who presented to his family doctor complaining of rectal bleeding. His history went back about 7 weeks when he noticed there were streaks of bright red blood coating his stool and spots of blood on the paper from time to time. There was also an embarrassing itch around his on many days. He was sure it was a case of hemorrhoids and he medicated himself daily with a suppository obtained from the local pharmacy. The condition seemed to have improved but he was alarmed by an unusually large smear of bright red blood on the toilet paper on the morning of his visit. The bleeding was not associated with pain. Further questioning revealed that he moved his bowel no more than 3 times a week, going to the toilet only when he felt the urge to go. Some degree of straining was always required and consistency of the stool was firm but not hard. There was no change in bowel habit and no family history of colonic cancer. He has always enjoyed good health.

1. What are the possible causes of rectal bleeding?

This patient’s chief complaint was painless bleeding of bright red blood per and he concluded that it was a case of hemorrhoids. He may very well be correct; blood shed by hemorrhoids is typically bright red because of arterio- venous communications in the complex. But patients’ description of blood in the stool is typically unreliable. As physicians, one should not overlook other possible causes of rectal bleeding. Many diseases of the lower gastrointestinal tract can present as blood of varying redness mixed with stool. They include , diverticular disease, inflammatory bowel disease (ulcerative , Crohn’s disease), . Even blood from the upper gastrointestinal tract can appear red if the bowel transit time is fast. In addition, hemorrhoids should be differentiated from rectal and anal varices found in patients with portal . Hemorrhoids and rectal/anal varices are http://www.medicine-on-line.com Hemorrhoids: 2/7

different entities. Previous believe that hemorrhoid can arise from and porto-systemic shunt is incorrect.

2. How should patients with suspected hemorrhoids be investigated?

Besides taking a relevant history from and performing a thorough physical examination on the patient, a careful anorectal evaluation by digital examination is warranted. While inspection of the lower gastrointestinal tract by and flexible is indicated in all patients, complete colonic evaluation by air-contrast barium or is reserved for patients in whom ƒ Rectal bleeding is atypical for hemorrhoids. ƒ Bleeding from hemorrhoids is not confirmed by anorectal examination. ƒ There are alarm features suggesting colonic neoplasm, which include: - Age over 50 years. - First degree relative with history of colon cancer. - Change of bowel habits. - Weight loss. - from chronic blood loss. Anemia due to hemorrhoids is rare.

Progress of the case—Examination of the patient revealed a middle age man looking his age, well nourished, and relaxed. His vital signs were normal; no abnormalities were found on examination of the cardio-respiratory system and abdomen. The anal margin was smooth and nothing was observed to have prolapsed from within. The wall of the was smooth to palpation; the sphincter tone was normal; no lump was palpable in the rectum; the was normal in size, shape, consistency and mobility; no blood or mucus was observed on the glove of the examining finger. An internal hemorrhoid with fresh bleeding point was observed at 3 o’clock just above the through the anoscope. Result of flexible sigmoidoscopy was normal. http://www.medicine-on-line.com Hemorrhoids: 3/7

3. What are hemorrhoids?

In the anal canal, there are submucosal cushions made up of vascular plexuses, , and fibers typically located in the right anterior, right posterior, and left lateral positions— although these positions may be variable. Internal hemorrhoids arise from congestion and dilatation of in these cushions above the pectinate line; they are covered by columnar or transitional . External hemorrhoids arise from congestion and dilatation of veins below the pectinate line; they are covered by anoderm. Internal hemorrhoids are further divided according to their degree of : ƒ First degree internal hemorrhoids bleed but do not prolapse. ƒ Second degree internal hemorrhoids bleed as well as prolapse through the anal margin but the prolapse reduces spontaneously. ƒ Third degree hemorrhoids bleed and prolapse but the prolapse requires manual reduction. ƒ Fourth degree hemorrhoids bleed as well as prolapse and the prolapse is irreducible by manual manipulation.

4. What are the clinical features of hemorrhoids?

Internal hemorrhoids ƒ The commonest presentation of internal hemorrhoids is painless rectal bleeding. Fresh blood that appears bright red may smear toilet paper, drip into the toilet bowl, or coat the surface of stool. Dark old blood or blood mixed in with the stool would suggest a more proximal bleeding site. The blood from hemorrhoids is bright red because there are arterio-venous communications within the complex. ƒ First degree internal hemorrhoids do not prolapse outside the anal margin. http://www.medicine-on-line.com Hemorrhoids: 4/7

ƒ Second degree internal hemorrhoids can present as mucous-membrane- lined protrusions at the anal margin when the patient is asked to bear down. ƒ Chronically prolapsed internal hemorrhoids can cause muco-fecal staining of underwear. ƒ Pruritis ani is a common complaint in patients with hemorrhoids. ƒ Pain is unusual and may suggest , incarceration, and even strangulation.

External hemorrhoids ƒ A thrombosed external hemorrhoid is an exquisitely tender, bluish-black nodule at the anal margin during the acute phase. ƒ If ignored the clot within reorganizes and the patient is left with a at the anal margin. ƒ Crevices associated with skin tags can render the maintenance of hygiene difficult, leading to development of reactive dermatitis.

5. What factors can promote the development of hemorrhoids?

Factors that lead to increase in abdominal pressure and straining can promote the development of hemorrhoids: ƒ Chronic . ƒ Straining during ; this can occur with constipation as well as . ƒ Prolonged sitting at the toilet. ƒ . ƒ . ƒ Holding back against urge to defecate. ƒ Sedentary lifestyle. ƒ Anal intercourse. http://www.medicine-on-line.com Hemorrhoids: 5/7

6. How should hemorrhoids be managed?

Uncomplicated chronic first, second, and some third degree hemorrhoids can be treated conservatively by medical therapy.

Medical therapy

o Treat constipation. (This topic was fully discussed in Case of the Week 034, http://www.medicine-on-line.com and is summarized below). ƒ Develop a regular bowel habit. ƒ Increase daily fiber intake to 20 – 30 grams. ƒ Increase non-caffeinated, non-alcoholic fluid consumption to at least 8 glasses per day. ƒ Increase daily physical activity. ƒ Avoid constipating medications. ƒ Use only safe laxatives like fiber supplements (e.g. psyllium) or stool softener (e.g. ). o Advise patient to go to the toilet in a timely fashion. Holding back against urge to defecate promotes straining. o Discourage patient from spending unnecessary time (e.g. reading) while sitting at the toilet. Sitting at the toilet for long periods also promotes straining. o Prescribe regular (sitting and bathing in a tub of warm water). It relieves irritation and improves perineal hygiene. o Anal suppositories (e.g. bismuth subgallate) are helpful. Hydrocortisone may be added for its anti-inflammatory effect but should be restricted to short term use only. Long term dependence on containing compounds can result in fungal supra-infection.

Hemorrhoids that failed medical therapy, advanced hemorrhoids, and hemorrhoids complicated by thrombosis should be referred to a colorectal surgeon. A number of office procedures are available for the treatment of hemorrhoids. http://www.medicine-on-line.com Hemorrhoids: 6/7

Office procedures

The following office procedures have the advantage of simplicity. But selection of patients and performance of the procedure require expertise and should not be undertaken by the inexperience.

o Elastic band ligation is a technique in which a rubber band is placed around the base of redundant hemorrhoid tissue with a special applicator. After a week to 10 days, the hemorrhoid sloughs off and scarring fixes the residual tissue to the rectal wall. This method is applicable only to internal hemorrhoids above the pectinate line covered by insensitive rectal mucosa. The patient will experience significant pain if the elastic band is applied to hemorrhoids in the transitional zone or below where the anoderm is richly supplied with nerve endings. o Injection is another technique used to treat internal hemorrhoids. A sclerosing solution is injected submucosally above the hemorrhoid complex to set off an inflammatory reaction that leads to scarring and re-attachment of redundant tissue to the rectal wall. o Infrared photocoagulation is a third office-based procedure but it is not suitable for large hemorrhoids with a significant amount of prolapse. o Cryosurgery uses a freezing probe to destroy redundant hemorrhoid tissue. Once a popular technique it has fallen into disuse because of disappointing results.

Operative treatment

o Excisional hemorrhoidectomy requires general or spinal anesthesia. It is reserved for hemorrhoids either not suitable for office-based procedures or where office-based procedure has failed. There are several variations to this open technique and all are associated with a significant amount of postoperative pain. o Staple hemorrhoidopexy is a newer technique also done under general or spinal anesthesia. In this procedure a circular strip of rectal mucosa above the http://www.medicine-on-line.com Hemorrhoids: 7/7

hemorrhoids is excised and its edges stapled together with a circular stapling instrument, thus elevating and restoring the vascular cushions back to their original anatomical position. This procedure is associated with less pain than that experienced after excisional hemorrhoidectomy.

Further readings

American Gastroenterological Association: Technical Review on the Diagnosis and Treatment of Hemmorrhoids. 2004;126:1463-73.