Rosen & Barkin's 5-Minute Emergency Medicine Consult (330 page)

• General:
  
  • Normal venous sinusoids of the distal rectum and proximal anal canal
    
  • Normal vascular cushions of anal canal that contribute to anal continence
    
  • Arteriovenous shunt system exists at the level of the internal hemorrhoids that accounts for the bright red blood per rectum
    
• When the hemorrhoids become symptomatic, hemorrhoid disease develops.
  
• Do not cause pain unless thrombosed or strangulated
  
• Discrete masses of thick submucosa contain:
  
  • Blood vessels
    
  • Smooth muscle
    
  • Elastic and connective tissue
    
• Sliding down of part of anal canal lining
  
• External hemorrhoids:
  
  • Vessels situated below dentate line
    
  • Covered by skin/anoderm
    
  • Drain to internal iliac veins
    
• Internal hemorrhoids:
  
  • Submucosal vessels above dentate lines
    
  • Drain to portal system
    
  • Usually at left lateral, right posterolateral, and right anterolateral positions
    
  • Grade 1: Painless, bleeding
    
  • Grade 2: Prolapse with bowel movement (BM), spontaneously reduce
    
  • Grade 3: Prolapse with BM, require manual reduction
    
  • Grade 4: Chronically prolapsed, not reducible
    

• Exact cause unknown
  
• Gravitational forces and abdominal pressure cause distention of the sinusoids
  
• Associated with straining and irregular bowel habits:
  
  • Hard, bulky stools or diarrhea cause tenesmus/straining.
    
  • Push anal cushions out of anal canal
    
  • Weaken submucosal tissue leading to prolapse
    
• Higher resting anal pressures:
  
  • Erect posture
    
• Heredity:
  
  • Absence of valves in veins
    
• Increased intra-abdominal pressure:
  
  • Ascites
    
  • Pregnancy
    
• Portal hypertension
  

DIAGNOSIS

• Painless, rectal bleeding with defecation
  
• Blood on stool or toilet paper
  
• Bright red blood drips into toilet bowel
  
• Rectal discomfort or pressure
  
• Severe pain if:
  
  • Internal hemorrhoids prolapse and strangulate
    
  • External thrombosed hemorrhoids
    
• Pruritus ani
  
• May also have fissure
  

• Length of bleeding
  
• Associate pain
  
• New lumps or masses by rectum
  
• Stool consistency: Hard or liquid
  
• Previous history of rectal problems
  
• Stool caliber
  

• Exam of perianal area:
  
  • Gently spread buttocks.
    
  • Discrete, dark blue, tender mass covered with skin: Thrombosed external hemorrhoid:
    
    • Can have internal component
      
  • Purplish, tender mucosal covered mass: Prolapsed, strangulated internal hemorrhoid:
    
    • Usually associated with enlarged, thrombosed external hemorrhoid
      
  • Have patient bear down to check for prolapsing hemorrhoids.
    
  • Digital rectal exam mandatory to rule out cancer
    
• Anoscopy to visualize anal canal:
  
  • Identify bleeding internal hemorrhoids.
    

Detailed history with thorough anorectal exam

• CBC if history of significant blood loss:
  
  • Hemoglobin/hematocrit
    
• Platelet count
  
• PT/PTT/INR if patient on anticoagulants or severe comorbid condition
  

• Rectal prolapse
  
• Anal fissure
  
• Perirectal abscess/fistula
  
• Condyloma acuminate
  
• Carcinoma or melanoma
  

TREATMENT

Establish IV access if severe bleeding

Direct digital pressure to control bleeding

• Conservative therapy for all patients:
  
  • Hot sitz baths for 15 min TID and after each BM
    
  • High-fiber diet—30 g/day:
    
    • Eat more fresh fruits and vegetables.
      
    • Increase bran intake.
      
  • 10–12 glasses of water per day
    
  • Stool softeners
    
  • Bulk-forming laxatives
    
• NSAIDs: Analgesic and anti-inflammatory effects
  
• Excise thrombosed external hemorrhoid if severe pain, <5 days old and clot not resolving:
  
  • Follow with conservative therapy.
    
  • Place patient in prone jackknife position or left lateral decubitus and tape buttocks apart
    
  • Infiltrate surrounding skin and underneath clot using 27G needle with lidocaine-containing epinephrine.
    
  • Make an elliptical incision to excise clot/skin.
    
  • May need silver nitrate sticks for hemostasis
    
  • Place a small piece of Gelfoam and/or gauze onto the wound and tape.
    
  • Remove dressing at time of 1st sitz bath in about 6 hr
    
  • Give analgesics:
    
    • NSAIDs
      
    • Acetaminophen
      
    • Lidocaine 5% ointment to anus: Topical anesthetic for pain relief
      
    • 0.2% topical nitroglycerin ointment to anus—decreases pain by inhibiting sphincter spasm
      
• Manually reduce nonthrombosed, prolapsed internal hemorrhoids:
  
  • Follow with conservative therapy.
    
  • May need topical anesthetic or anal sphincter block with local anesthesia
    
  • Can sclerose bleeding internal hemorrhoids with 2.5% sodium morrhuate or 3% hypertonic saline
    
  • Can rubber band ligate 1 or 2 internal hemorrhoids:
    
    • Avoid in immunocompromised patients due to perineal sepsis
      
• Nonreducible internal hemorrhoids:
  
  • Nonstrangulated: Conservative management and surgical referral
    
  • Strangulated: Immediate surgical referral for excision
    

• Usually become symptomatic in the 3rd trimester and can be treated conservatively.
  
• Do not use Analpram-HC (class C)
  

• Acetaminophen: 325–650 mg (peds: 15 mg/kg) with codeine 15–30 mg (peds: 0.5 mg/kg) PO q4h PRN
  
• Bran/fiber: 20 g PO daily
  
• Docusate sodium (Colace): 50–200 mg (peds: <3 yr, 10–40 mg/d; 3–6 yr, 20–60 mg/d; >6–12 yr, 40–150 mg/d) PO q12h
  
• ELA-Max 5 (5% lidocaine anorectal cream): Apply to perianal area q4h PRN pain (peds: not for <12 yr of age). Caution: Use very small amount; this product contains about 5 g lidocaine/100 g cream and is readily absorbed.
  
• Hydrocortisone/pramoxine topical (Analpram-HC) 1%/1% cream; 2.5%/1% cream/lotion (peds: Same dosing) apply thin amount to area TID–QID
  
• Hydrocortisone/lidocaine topical (AnaMantle HC) 0.5%/3% cream; 2.5%/3% gel (peds: Not indicated) apply to anal canal BID
  
• Ibuprofen (Motrin): 400–600 mg (peds: 40 mg/kg/d) PO q6h
  
• Nitroglycerin 0.2% ointment: Apply to area TID with cotton-tipped applicator
  
• Psyllium seeds: 1–2 tsp (peds: 0.25–1 tsp/d) PO q24h
  

FOLLOW-UP

• Strangulated grade 4 hemorrhoids:
  
  • Surgical consult for prolapsed, thrombosed internal hemorrhoids
    
• Severe anemia with bleeding hemorrhoids
  
• Severe bleeding hemorrhoid in pt on anticoagulation or with portal hypertension
  

Most patients will go home

Surgical referral for:

• Grade 3 or 4 internal hemorrhoids
  
• Suspected anorectal or colonic tumors, inflammatory bowel disease, coagulopathy, pregnancy, or immunocompromised
  

• Colorectal follow up for grade 3 or 4 internal hemorrhoids or suspected tumor
  
• Primary care follow-up for uncomplicated hemorrhoids.
  

Hemorrhoids are not the only cause of anorectal pain and bleeding. Investigate for other etiologies when indicated.

• Acheson AG, Scholefield JH. Management of hemorrhoids.
  BMJ.
  2008;336(7640):380–383.
  
• Kaider-Person O, Person B, Wexner SD. Hemorrhoidal disease.
  J Am Coll Surg.
  2007;204(1);102–117.
  
• Lohsiriwat V. Hemorrhoids: From basic pathophysiology to clinical management.
  World J Gastroenterol
  . 2012;18(17):1009–1017.
  
• Wexner SD, Pemberton JH, Beck DE, et al., eds.
  The ASCRS Textbook of Colon and Rectal Surgery
  . New York, NY: Springer; 2007.
  

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