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6.10 Hemorrhoids (Piles)


Presentation

Patients with external hemorrhoids generally complain of a painful purple lump covered with anal skin. It may have been precipitated by straining during defecation, heavy lifting, or pregnancy, but in most cases there was no definite preceding event. The external hemorrhoidal swelling is caused by thrombosis of the vein and is very tender to palpation and usually does not bleed unless there is erosion of the overlying skin.

Patients with internal hemorrhoids usually seek help because of painless (or nearly painless) bright red bleeding at the time of defecation. Patients usually notice intermittant spotting on toilet tissue or episodic streaking of stool with blood. A prolapsed internal hemorrhoid appears as a protrusion of painless, moist red mass covered with rectal mucose at the anal verge. Prolapsed internal hemorrhoids may become strangulated and thrombosed, and thus painful. Itching is not a common symptom of hemorrhoids

What to do:

What not to do:

Discussion

The pathogenesis of hemorrhoids is multifactorial. Predisposing factors include heredity, portal hypertension, straining to defecate, and pregnancy. Internal hemorrhoids are classified into four groups. First-degree internal hemorrhoids do not protrude, cannot be palpated by digital examination, and require anoscopy for diagnosis. Second-degree hemorrhoids protrude with defecation, but reduce spontaneously. Third-degree hemorrhoids protrude and require manual reduction. Fourth-degree hemorrhoids are irreducibly prolapsed. Elastic banding techniques can be 80-90% curative for second, third and fourth degree internal hemorrhoids, but can increase prolapse of first-degree hemorrhoids. Patients with bleeding diatheses, prolapse or both internal and external hemorrhoids are best treated by surgical resection. The diagnosis of "hemorrhoids" may cover a variety of minor ailments of the anus, which may or may not be related to the hemorrhoidal veins. The ED approach consists of ruling out immediately life-threatening problems, and then providing the patient with symptomatic relief and appropriate referral.

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from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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Craig Feied, MD
Mark Smith, MD
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