Editing Haemorrhoids (section)

== '''Presentation''' ==

* Most commonly painless bright     red bleeding with bowel movements, and sometimes a lump
* Key factors are the extent,     severity and duration of symptoms; issues of perineal hygiene; and     presence or absence of pain
* Discuss fibre intake and     bowel habits
* Anorectal examination to     evaluate the extent of haemorrhoidal disease and search for other     abnormalities

=== '''Strangulated     internal haemorrhoid (sometimes called thrombosed)''' ===

** Irreducible haemorrhoids,      but shouldn't cause too much pain due to less somatic innervation. Still      sometimes can cause pain with necrosis.
** Can become necrotic and      bloody
** If no necrosis, attempt      manual reduction and treat with sitz baths, ice and analgaesia; but      better not to attempt reduction if there is necrosis
** High-risk for stricture      formation to do a haemorrhoidectomy in this setting, therefore most      surgeons won't do it. If you are operating, be very careful with tissue      planes, internal sphincter preservation, and haemostasis. Preserve as      much anoderm and mucosa as possible, to prevent stricture formation.
** Ideally, manage      conservatively until fully settled, then offer haemorrhoidectomy
** Those with incarceration,      strangulation and necrosis should have a haemorrhoidectomy

=== '''Thrombosed     external haemorrhoid''' ===

**
** Lots of variation in      semantics, but many say this is the same entity as a perianal haematoma -      others differentiate between the two and call a perianal haematoma an      extravascular haematoma which gives a more circular lump, probably with a      skin bridge, NOT mucosa
** Acute severe pain,      exacerbated by sitting or defecation, which may be preceded by an episode      of constipation or diarrhoea
** Can sometimes be complicated      by necrosis, which should usually have some sort of external      manifestation - surrounding cellulitis or systemic features
** Usually associated with      internal haemorrhoids too, but those usually remain soft because the      thrombosis is in the superficial channels
** Usually resolves within 72      hours
** Trial sitz baths, topical      lignocaine and stool softeners
** Surgery for severe pain or      significant bleeding - excise the thrombosed haemorrhoid but leave the      rest alone

=== '''Acute     bleeding''' ===

** Haemorrhoidectomy is      generally favoured to banding, as bleeding can be worsened when the band      sloughs off, especially if the patient is anticoagulated
** If can't stop      anticoagulation for 7-14 days, better off with formal haemorrhoidectomy