Haemorrhoids
Today, we're diving into the fascinating world of hemorrhoids. Let's get started!
So, what exactly are hemorrhoids? Well, they're dilated submucosal vascular cushions found in the anal canal. These cushions consist of arteriovenous blood vessels, smooth muscle, and fibroelastic tissue.
Hemorrhoids can be caused by a variety of factors, including excessive straining during bowel movements (often due to constipation), extended periods of sitting, and even pregnancy due to increased intra-abdominal pressure and hormonal changes.
Now, let's talk about classification. Hemorrhoids can be categorized as internal (located above the dentate line), external (below the dentate line), or mixed.
The main difference between internal and external hemorrhoids lies in their innervation. Internal hemorrhoids develop above the dentate line and receive visceral innervation from pelvic splanchnic nerves. On the other hand, external hemorrhoids develop below the dentate line and are innervated by the pudendal nerve, leading to pain sensation, especially during defecation if thrombosed.
Clinical features vary between internal and external hemorrhoids. Internal hemorrhoids typically present with painless bright red bleeding during defecation and may also cause pruritus. External hemorrhoids, on the other hand, are often painful and also present with bright red bleeding during defecation if thrombosed.
Now, let's talk about grading. Internal hemorrhoids are graded based on the degree of prolapse:
Grade 1: Bleeding without prolapse
Grade 2: Prolapse with straining, spontaneously reduce at rest
Grade 3: Prolapse with straining, manually reducible
Grade 4: Irreducible prolapse, potentially leading to strangulation and thrombosis
Diagnosis of hemorrhoids typically involves a perianal exam, digital rectal exam (DRE), and anoscopy. In cases where diagnosis is inconclusive or if there's a suspicion of malignancy, additional tests such as proctoscopy, flexible sigmoidoscopy, or colonoscopy may be warranted.
Treatment of hemorrhoids often begins with lifestyle modifications such as increasing fiber and fluid intake to reduce straining, along with sitz baths for pain relief. For internal hemorrhoids grades 1-3 unresponsive to conservative measures, rubber band ligation may be performed, while grade 4 hemorrhoids may require hemorrhoidectomy.
Now, let's touch on a complication of external hemorrhoids: thrombosis at the inferior hemorrhoidal plexus. This presents as an acute onset of perianal pain and a tender, purple nodule at the anal verge. While most cases resolve spontaneously within a few days, surgical excision may be necessary if conservative treatment fails.
Remember, it's essential to differentiate between perianal hematoma and thrombosed internal hemorrhoids, as their management can differ significantly.