Hemorrhoids

Hemorrhoids 101 - Piles Primer

• Definition: Symptomatic, engorged vascular cushions in the anal canal.
• Anal Cushions: Normal submucosal structures (left lateral, right anterior, right posterior). Contain AV shunts.
• Types (based on relation to Dentate Line):
  • Internal: Proximal to dentate line. Columnar epithelium. Visceral innervation (painless).
    • Goligher's Classification:
      • Grade I: Bleeding, no prolapse.
      • Grade II: Prolapse on straining, reduces spontaneously.
      • Grade III: Prolapse, requires manual reduction.
      • Grade IV: Irreducible prolapse, may strangulate.
  • External: Distal to dentate line. Squamous epithelium. Somatic innervation (painful).
• Etiology: Straining, constipation, pregnancy, portal hypertension, prolonged sitting.

⭐ The primary locations of internal hemorrhoids are right anterior (11 o'clock), right posterior (7 o'clock), and left lateral (3 o'clock) in lithotomy position.

Etiology & Symptoms - Strain & Pain Story

• Etiology (The "Strain" Factors):

  • Chronic straining: constipation, diarrhea
  • ↑ Intra-abdominal pressure: pregnancy, obesity, heavy lifting, chronic cough
  • Prolonged sitting, low-fiber diet
  • Age-related connective tissue degeneration
  • Family predisposition
  • 📌 Mnemonic: "PUSH" (Pregnancy/Pressure, Urge/straining, Sitting prolonged, Hard stools)

• Symptoms (The "Pain & Bleed" Story):

  • Painless rectal bleeding: Bright red blood on stool/tissue, or dripping. (Most common)

    ⭐ Internal hemorrhoids typically present with painless bleeding; pain suggests thrombosis (external/internal) or strangulation (prolapsed internal).

  • Anal pain/discomfort: Especially if thrombosed or strangulated.
  • Pruritus ani (itching)
  • Perianal mass/lump (palpable)
  • Mucous discharge
  • Sensation of incomplete defecation

Diagnosis & DDx - Anal Detective Work

• Diagnosis:

  • History: Painless bright red rectal bleeding (on tissue/stool), prolapse, discomfort, pruritus.
  • Perianal Inspection: External hemorrhoids, prolapsed internal, skin tags, fissures.
  • DRE: Assess tone, rule out mass. Internal hemorrhoids usually not palpable unless thrombosed.
  • Anoscopy/Proctoscopy: Confirms diagnosis; visualizes & grades internal hemorrhoids.

• Differential Diagnosis:

  • Anal Fissure (severe pain with defecation)
  • Colorectal Cancer (red flags: weight loss, altered bowel habits, older age)
  • IBD (diarrhea, abdominal pain)
  • Rectal Prolapse

⭐ Proctosigmoidoscopy/colonoscopy may be needed in patients >40 years or with red flags to exclude malignancy.

Management Matrix - Taming the Troubles

• Conservative (Grade I, uncomplicated II): 📌 Mnemonic: WASH
  • Water (Sitz baths: warm, 15 min, TID)
  • Analgesics/Topicals (anesthetics, steroids - short term, venotonics e.g., Daflon)
  • Stool softeners & ↑Fluids
  • High-fiber diet (25-35g/day), avoid straining.
• Office Procedures (Grade I-II refractory, select III):
  • Rubber Band Ligation (RBL): Most common, effective.
  • Sclerotherapy: Injection (e.g., 5% Phenol in oil).
  • Infrared Coagulation (IRC).
• Surgical (Grade III refractory, Grade IV, complications e.g., thrombosis, strangulation):
  • Conventional Hemorrhoidectomy:
    • Milligan-Morgan (open): Leaves wounds open for secondary intention.
    • Ferguson (closed): Primary wound closure.
  • Stapled Hemorrhoidopexy (PPH/Longo): For circumferential prolapse. Reduces pain, faster recovery.
  • Doppler-guided Hemorrhoidal Artery Ligation (HAL) +/- Recto-Anal Repair (RAR).
• Acute Thrombosed External Hemorrhoid:
  • Conservative: Pain relief, sitz baths, stool softeners.
  • Excision if severe pain & within 48-72 hours of onset.

⭐ Milligan-Morgan hemorrhoidectomy is an open technique leaving wounds for secondary intention healing, while Ferguson is a closed technique with primary wound closure anastamosis of rectal mucosa to anodermis .

High‑Yield Points - ⚡ Biggest Takeaways

• Internal hemorrhoids are typically painless with bright red bleeding; external hemorrhoids are painful.
• Grading (I-IV) of internal hemorrhoids is key for selecting appropriate management.
• Conservative treatment (high-fiber diet, sitz baths) is first-line for early grades.
• Rubber band ligation is a common, effective OPD procedure for Grade II and III internal hemorrhoids.
• Surgical hemorrhoidectomy (e.g., Milligan-Morgan) is reserved for Grade III/IV or complicated cases.
• Acute thrombosed external hemorrhoid presents as a painful perianal lump; consider excision if presenting within 72 hours.