Hemorrhoids: Clinical sciences

Hemorrhoids are a type of varicose veins in the anorectum that form when there is a persistently elevated venous pressure in the hemorrhoidal plexus. Based on the location to the dentate line, hemorrhoids can be classified as external, which are located distal to the dentate line; internal, which are located proximal to it; and combined, which are found on both sides of the dentate line.

Alright, the first step when approaching a patient with signs and symptoms suggestive of hemorrhoidal disease is to obtain a focused history and physical examination. Patients with external hemorrhoids typically present with a history of palpable external lump, anal pruritis, and perianal pain, usually without bleeding. In some individuals, they can become thrombosed and cause excruciating pain. Next, on examination of the anal verge and perianal area, uncomplicated external hemorrhoids may appear as tender, soft, swollen, red lumps. Additionally, patients may have non tender skin tags from previous episodes of inflammation and thrombosis. On the other hand, an acutely thrombosed external hemorrhoid will be firm and extremely tender to palpation and may have a purplish hue.

On the flip side, individuals with internal hemorrhoids typically present with painless bleeding with defecation, anal pruritis, and a prolapse. The prolapse might spontaneously reduce, require manual reduction, or even be unreducible, which is also known as incarceration. Now, incarceration can slow blood flow in the veins, leading to thrombosis. It can also cut off blood flow completely causing ischemia, and this is known as strangulation. Both of these complications can cause excruciating pain. On a digital rectal exam, internal hemorrhoids are generally not visible or palpable; however, they might be palpable if thrombosed, strangulated, or prolapsed. Finally, some individuals might have combined internal and external hemorrhoids and present with symptoms and signs of both types.

Alright, after the history and physical, you should be able to determine the type of hemorrhoid, so let’s look at external hemorrhoids first. Uncomplicated external hemorrhoids can be treated with non-surgical management, which includes sitz baths, a high fiber diet, increased fluid intake, and stool softeners. However, if non-surgical management is not effective, consult a surgeon for possible excisional hemorrhoidectomy.

On the other hand, if a patient with complicated or thrombosed external hemorrhoids presents within four days of thrombosis, they can be managed by an office-based incision of hemorrhoid to relieve pain. If the thrombosed hemorrhoids are too large to manage in the office, consult a surgeon for excisional hemorrhoidectomy. Alternatively, patients that present after the first four days of thrombosis should be treated non-surgically. This is because the thrombus will be gradually reabsorbed over time and the risk of the surgery outweighs the potential benefits.