Hemorrhoids: Clinical sciences

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Introduction0:00–0:26

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.

History and Physical0:26–2:12

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.

External hemorrhoids2:12–3:14

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.

Internal hemorrhoids3:14–5:19

Now, when it comes to patients presenting with signs and symptoms suggestive of internal hemorrhoids, we start with an endoscopic evaluation.
We can first use anoscopy to evaluate the anal canal and rectum and confirm the diagnosis. Additionally, in individuals older than 40 years, use colonoscopy or sigmoidoscopy to exclude other distal anorectal conditions that also present with rectal bleeding, such as colorectal cancer or inflammatory bowel disease.
Next, based on the severity of prolapse, internal hemorrhoids can be classified into four grades. Grade one hemorrhoids do not prolapse; while grade two hemorrhoids do prolapse during bowel movements or straining, but reduce spontaneously.
Grade three hemorrhoids prolapse and require manual reduction. Finally, grade four hemorrhoids are irreducible even with manipulation.Alright, grades one, two, and three should be treated with non-surgical management just like uncomplicated external hemorrhoids.
However, if the treatment is not effective, a surgery consultation should be called to determine the best treatment option.
These include rubber band ligation, sclerotherapy, and infrared coagulation. Alternative options for grade three hemorrhoids include Doppler-guided hemorrhoidal ligation with artery ligation, hemorrhoidopexy, as well as mucopexy, or stapled hemorrhoidectomy.
If office-based interventions are not an option, consult a surgeon for excisional hemorrhoidectomy.Finally, the treatment of grade four internal hemorrhoids depends on the presence of strangulation or incarceration.
The first-line treatment for grade four hemorrhoids without strangulation or incarceration is non-surgical management; while the second-line treatment includes surgical consultation for excisional hemorrhoidectomy.
On the flip side, if the patient presents with acute incarceration or strangulation, skip the non-surgical management and consult a surgeon for excisional hemorrhoidectomy.
Finally, let’s take a look at combined internal and external hemorrhoids. An individual may have an external hemorrhoid on examination, but may also report symptoms such as bleeding, which make you suspect an internal hemorrhoid.

Combined external and internal5:19–5:58

In this case, your first step would be to perform anoscopy to confirm the diagnosis and rule out complications. When it comes to treatment for combined hemorrhoids, conservative or non-surgical management is the first choice.
However, if the non-surgical management is not effective or hemorrhoids are thrombosed, you should consult a surgeon for excisional hemorrhoidectomy.Alright, as a quick recap… You can determine if a hemorrhoid is internal or external or combined based on the individual’s history and physical.

Review5:58–6:59

Uncomplicated external hemorrhoids are typically treated with non-surgical management, such as sitz baths and high-fiber diet.
However, complicated external hemorrhoids usually require surgical interventions, such as excisional hemorrhoidectomy. This can depend on the time frame.
If they present within four days of thrombosis, proceed with surgical interventions, but if they present after four days, initiate non-surgical management.
Next, internal hemorrhoids should be explored with endoscopy to grade the degree of prolapse. Grades one, two, and three are typically treated with non-surgical management.
On the flip side, complicated grade four internal hemorrhoids require surgical interventions. Lastly, individuals with combined external and internal hemorrhoids are treated non-surgically initially unless there’s thrombosis.