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Snap Shot
  •  A 54-year-old female with a history of alcohol abuse presents with complaints of a mass in his anus.
Introduction
  • Engorgement of venous plexus derived from:
    • superior hemorrhoid vein (internal hemorrhoids) 
    • inferior hemorrhoid vein (external hemorrhoids)
  • Predisposing factors include:
    • pregnancy
    • straining at stool
    • constipation
    • cirrhosis with portal hypertension
      • causes anorectal varices not to be confused with hemorrhoids
  • Thrombosed external hemorrhoid
    • not a true hemorrhoid
    • caused by subcutaneous external hemorrhoids of anal canal
  • Classified by degree:
    • 1st degree: does not prolapse
    • 2nd degree: prolapses with defecation, spontaneously reduces
    • 3rd degree: polapses with defecation, requires manual reduction
    • 4th degree: can not be reduced
Presentation
  • Internal hemorrhoids
    • Anal mass / prolapse
    • Bleeding
  • External hemorrhoids (below dentate line)
    • pain
    • itching
    • bleeding
  • Thrombosed external hemorrhoid
    • excruciating pain with history of hemorrhoids
    • bluish elevation of skin
Evaluation
  • Rectal exam, anoscope, sigmoidoscopy  
Treatment
  • Conservative treatment:
    • proper dietary (fiber) and bowel habits
    • sitz bath
    • stool softeners
    • cortisone cream
  • Definitive Treatment
    • banding
    • cryosurgery
    • sclerotherapy
    • laser surgery
    • hemorrhoidectomy for large refractory hemorrhoids
      • contraindicated in Crohns disease
  • Thrombosed external hemorrhoids
    • sitz baths
    • stool softeners
    • or in severe cases excision of skin with evacuation of the thrombus
Prognosis, Prevention, and Complications
  • Exsanguination (may not have signs of external bleeding)
  • Pelvic infection
  • Incontinence
  • Thrombosis
  • Strangulation
  • Ulceration
  • Infection
  • Anal fissures
 

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