History Initial PE and Labs Location & Clinical Manifestations

Initial Impression
• Internal Hemorrhoids
36 yo, Female, G2P2(2002)
are cushions of submucosal tissue containing venules, o Located proximal to the dentate
Chief Complaint: Blood in the stool PE: tight sphincter tone Wbc 12,000 line and covered by insensate
arterioles, and smooth muscle fibers that are located in the
1 month PTA (+) blood on the stool, no associated symptoms, usual BM (+) Palpable mass at Left Lateral Hgb 9.7 anal canal anorectal mucosa
• Hemorrhoids
every 3-4 days and Right Anterior portion Hct 29.1 o Bleeding
• Rectal Prolapse
3 weeks PTA, (+) protruding mass at the anal area, with spontaneous (+) Blood on examining finger Plt 166,000 o Tissue Prolapse
• Colorectal Carcinoma
reduction Urinalysis: unremarkable • External Hemorrhoids
1 week PTA, persistence of anal mass but now requiring manual o located distal to the dentate line
reduction, with (+) anal pain aggravated during defecation and are covered with anoderm
o Pain
o Pruritus
Due to the history, symptoms and physical o Skin Tags
examination, patient more likely has

Diagnostics Risk Factors Etiopathogenesis

1. Rectal Prolapse
• Is full-thickness protrusion of the rectum through the anus • Family history
• Was considered because: • Prolonged sitting/ Sedentary lifestyle Advancing age, diseases with increased
• Definitive: Anoscopy
o Patient is female and disease is common among them, with a female-to-male ratio of 6:1 o Evaluate and grade internal • Old age abdominal pressure, straining,
• Yet, was less likely because: hemorrhoids they prolapse into o Weakening fibers of Treitz’s muscle prolonged sitting, pregnancy
o This is prevalent in women at their 7th decade, yet patient is around half that age the slot • Increased intra-abdominal pressure ↓
o Symptoms include tenesmus, a sensation of tissue protruding from the anus that may or may not • Colonoscopy/ Proctoscopy/ o COPD Abnormal venous dilatation, vascular
spontaneously reduce, and a sensation of incomplete evacuation, which is not seen in the patient Sigmoidoscopy o Patients who chronically strain thrombosis, degeneration of collagen
o To rule out malignancy, polyps, or  Strenuous heavy lifting fibers and fibroelastic tissues (sliding
2. Colon Carcinoma masses, other causes of bleeding  Low fiber, high fat diet anal canal theory), distortion and
• CBC o Patients with a space-occupying rupture of the anal subepithelial muscle,
• Is full-thickness protrusion of the rectum through the anus
o Assess severity of anemia and intraabdominal lesion: ovarian inflammatory reaction has been
• Was considered because:
need for blood transfusion tumor or large rectosigmoid associated with mucosal ulceration,
o Although, it is less likely given that patient is less than 50 years old, there have been increasing cases of
• External Examination carcinoma ischemia
colon cancer found in the younger age group o To assess presence of o Patients with ascites/ portal ↓
o Patient experienced rectal bleeding, which is a classic symptom of this disease thrombosed external hypertension Bleeding, thrombosis, symptomatic
• Yet, was less likely because: hemorrhoid, skin tags, fistulas o Pregnancy hemorrhoidal prolapse
o Patient has no known significant risk factor for this disease o Obesity
o There is no change of bowel movement or stool caliber, as well as weight loss and poor appetite

As the patient presents with symptoms of bleeding, prolapse , palpable masses at the left lateral
and right anterior portion via DRE, with no noted external lesions, it is highly likely that patient has

Is a partial-thickness protrusion often associated with mucosal prolapse

Medical Management
Grading
Surgical Procedure
1. Lifestyle changes
• Increased water intake Procedure Grading Comment Complications • First Degree
• Physical activity o Bulge into the anal canal and may prolapse beyond
2. Fiber supplementation up to 26 g daily • Severe post-operative pain the dentate line on straining
• Long-term sequelae include • Second Degree
3. Warm sitz baths two to three times daily As patient has bleeding • Gold standard
Hemorrhoidectomy III, IV incontinence, anal stenosis, and o Prolapse through the anus but reduce spontaneously
4. If stools remain hard, stool softeners such as docusate sodium, can be used Grade III internal • The vascular pedicle of the hemorrhoidal bundle is ligated
ectropion (Whitehead’s deformity) • Third Degree
5. Over-the-counter products hemorrhoids, surgical
procedure is advised o Prolapse through the anal canal and require manual
• Provide temporary relief from pain, itching, burning, and lubrication reduction
• Some products contain local anesthetics such as benzocaine, lidocaine, and pramoxine • Chronic anal pain
• Best suited for patients with second- and third-degree hemorrhoids • Bacteremia • Fourth Degree
• Some other active agents include vasoconstricting substances such as epinephrine, phenylephrine, or ephedrine o Prolapse but cannot be reduced and are at risk for
• A circular stapling device creates a mucosa-to-mucosa anastomosis by excising the • Rectovaginal fistula
• Barrier products include alimentum hydroxide gel, cocoa butter, mineral oil, zinc oxide, starch, and petrolatum Stapled strangulation
III, IV submucosa proximal to the dentate line • Formation of an obstructing rectal
• Corticosteroids can be used as well, which provide anti-inflammatory relief Hemorrhoidopexy
• There is a cephalad relocation of the anal cushions and interruption of the feeding stricture
• Prolonged ( > 4weeks)and incorrect use of these products may result in thinning of the perianal skin or exacerbation arteries • Rectal perforation
of symptoms • Increased risk of recurrence
6. Phlebotonics are a heterogenous group of compounds including plant extracts or flavonoids
• Superior in treating acute hemorrhoid symptoms, improving venous tone, stabilize capillary permeability Doppler-Guided
• uses an anoscope fashioned with a Doppler probe to identify each hemorrhoid artery
Hemorrhoidal Artery I, II • Bleeding
• Useful in alleviating bleeding from hemorrhoids that is subsequently ligated
Ligation
• have an excellent safety profile

Note: Medical management is usually offered to patients with Grade I and II internal hemorrhoids as the first line of
treatment

Pre-Operative Operative Post-Operative

In cases that medical treatment fails, office-based procedures are done

• Bowel enema is done to clean out distal

bowel
Endoscopic Treatment/ Office Procedures
• IV fluids: Ringer's Lactate 2 hours prior
to surgery
• IV fluids: Ringer's Lactate
• Place patient on ERAS protocol with no
Definitive Treatment: • Soft diet resumed once tolerated
Procedure Grading Comment Complications solids 6 hours prior to surgery but may
Hemorrhoidectomy • Continue Antibiotics
clear liquids up until 2 hours before
• Patient is in left lateral decubitus • Opioid as needed for pain
surgery
• One to 3 mL of a sclerosing solution is injected into the submucosa of each • Pain on injection site
hemorrhoid • Ulceration/ scarring • Antibiotic Prophylaxis: Cefazolin sodium
Sclerotherapy I, II, III • The most commonly used sclerosant agents are 5% phenol in almond or vegetable oil • Bleeding 2g/IVTT one dose one prior to surgery
or sodium tetradecyl sulfate • Infection
• Mechanism of action is fibrosis of the submucosa with subsequent fixation of the
hemorrhoidal tissue

• Most common office procedure

• Patient is in left lateral decubitus • Urinary retention
Rubber Band Ligation • Ligation of the hemorrhoidal tissue results in ischemia and necrosis of the prolapsing • Bleeding
I, II, III
(RBL) mucosa followed by scar fixation to the rectal wall • Necrotizing infection
• Avoidance of blood thinners for at least 7 days reduces the risk of posthemorrhoidal o Severe pain, fever
banding bleed

• The instrument is applied to the apex of each hemorrhoid to coagulate the

• Similar to both sclerotherapy and
Infrared Coagulation I, II underlying plexus
RBL • Brunicardi, F., & Anderson, D. (2019). Schwartz's principles of surgery. (11th ed.). McGraw-Hill.
• The end effect is scarring and fixation of the hemorrhoid
• Cameron, J., & Cameron A. (2020). Current Surgical Therapy. (13th ed.). Elsevier.
• Feldman, M., Brandt, L., Friedman, L. (2020). Sleisenger and Fordtran's Gastrointestinal and Liver Disease. (11th ed.). Elsevier.
Note: If patients still do not respond to non-operative management and office-based procedures, surgical intervention is required. It is also reserved for mixed • Jameson, J.L., Fauci, A.S., Kasper, D.L., Hauser, S.L., Longo, D.L., Loscalzo, J. (2019) Harrison’s Principles of Internal Medicine (20th ed.). McGraw Hill Education
hemorrhoids with internal and external components or grade III to IV internal hemorrhoids with bleeding. • Davis, Bradley R. M.D.; Lee-Kong, Steven A. M.D.; Migaly, John M.D.; Feingold, Daniel L. M.D.; Steele, Scott R. M.D. The American Society of Colon and Rectal Surgeons
Clinical Practice Guidelines for the Management of Hemorrhoids, Diseases of the Colon & Rectum: March 2018 - Volume 61 - Issue 3 - p 284-292. doi:
10.1097/DCR.0000000000001030