What you need to know regarding hemorrhoids at primary care

1. HAEMORRHOID MANAGEMENT
IN PRIMARY CARE
Dr Vairam
31/3/2022

2. Definition
Haemorrhoids are swollen blood vessels in the lower rectum
https://emedicine.medscape.com/article/775407-overview

3. Risk Factors
• Constipation
• Straining during defecation
• Heavy lifting
• Prolonged sitting period
• Obesity
• Pregnancy
https://www.osmosis.org/answers/thrombosed-hemorrhoid

4. Pathophysiology
• Exact pathophysiology of hemorrhoidal development is poorly understood
• Theory of sliding anal canal lining is widely accepted now
This proposes that hemorrhoids develop when the supporting tissues of the anal
cushions
disintegrate or deteriorate
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/

5. Anatomy
• Anal cushions
—> Areas of thickened anal mucosa that consist of arteriovenous blood vessels, smooth
muscle,
and fibroelastic tissue
—> Play an important role in maintaining continence by enabling tight closure of the
rectum
—> Located at 11, 7 and 3 o'clock in the lithotomy position
(right anterior, right posterior, and left lateral position)
https://www.amboss.com/us/knowledge/Hemorrhoids#Z404bcdc1a50406476036e09f0a0f4240

6. Diagram of common sites of major anal and internal hemorrhoids.
A: Diagram of common sites of major anal cushions;
B: Common sites of internal hemorrhoids.

7. • Dentate line
—> Circular separation line formed by the
fusion of anal valves
—> Divides anal canal into an upper and
lower part
https://www.amboss.com/us/knowledge/Hemorrhoids#Z404bcdc1a50406476036e09f0a0f4240

8. Classification
• External haemorrhoids
• Internal haemorrhoids
1st / 2nd / 3rd & 4th degree

9. Painless
Becomes painful when swollen

11. Clinical Features
Internal hemorrhoids
•Often painless, bright red bleeding at the end of defecation
•Perianal mass in the event of prolapse
•Pruritus
•Anal discharge (containing mucus or fecal debris)
•Ulceration (in hemorrhoid stage IV)
External hemorrhoids
•Manifestations are similar to those of internal hemorrhoids (i.e., bright red
bleeding, pruritus, perianal mass)
•A thrombosed external hemorrhoid manifests with severe perianal pain and a tender
perianal mass

12. Complications
• Thrombosis: Due to strangulation of the blood supply which leads to severe pain with
swollen bluish external haemorrhoid. Can lead to gangrene, infection, ulceration.
• Massive bleeding: Unusual to bleed profusely until hypovolaemic shock requiring
blood transfusion. Chronic regular bleed can lead to iron deficiency anaemia.
• Incontinence: Poor sealing mechanism from displacement of anal cushions,
compounded by sensory impairment around anal canal causing pruritus, minor
soiling, leakage of mucus and liquid feces.
• Strangulation

13. Approach
History
• Presenting complaint - mass PR, PR bleeding, Pruritus ani, Painful/Painless
• Risk factors - Obesity, Constipation, Pregnancy or postpartum (episiotomy),
Occupation/Life style (prolonged sitting/heavy lifting)
• Red Flag Symptoms - Weight loss, Abdominal pain, Fever, Signs of anemia
• Malignancy - Personal or family history of colorectal cancer
• Inflammatory bowel disease - Crohn's disease and ulcerative colitis

14. • Risk factors for colorectal cancer include:
Family history of colorectal cancer
Adenomatous polyps
Inherited cancer syndromes such as familial adenomatous polyposis or hereditary
nonpolyposis colorectal cancer
https://www.aafp.org/afp/2018/0201/p172.html#sec-2

15. • > 40 years with rectal bleeding and younger patients with risk factors should undergo
full colon evaluation by colonoscopy, computed tomographic colonography, or barium
enema, unless they have had a normal colon evaluation within the previous 10 years
• Close follow-up is important in patients with rectal bleeding who do not undergo
endoscopy because the incidence of colorectal cancer in younger adults is rising, with
patients born in 1990 having twice the lifetime risk of a patient born in 1950
https://www.aafp.org/afp/2018/0201/p172.html#sec-2

16. Physical Examination
• Abdominal examination - mass per abdomen
• Local examination:
Perineal and rectal areas should be inspected - presence of external hemorrhoids or
prolapse of internal haemorrhoids may be obvious
A digital rectal examination can detect masses, tenderness, and fluctuant - TRO Ca
rectum, haemorrhoids cannot be felt unless thromboses or fibrosed
Proctoscopy - to visualize internal haemorrhoids

17. Investigation
• FBC - anemia
• Stool occult blood (If no gross PR bleeding) - TRO GI malignancy
• TFT - constipation
• ESR - raised in IBS
• Rigid / flexible sigmoidoscope, Colonoscopy, Barium enema - To look for other cause
of PR bleeding

18. https://www.aafp.org/afp/2018/0201/p172.html#s
ec-2

19. What can be offered at Primary Care

21. • Investigating cause of constipation - TFT, medication review (Eg: opioids, TCA, Iron
supplements), inadequate fluid or fiber intake in the diet, changes in habits or lifestyle
(pregnancy, old age, exercise)
• Life style and diet modification - Counselling / Dietitian referral
https://www.hopkinsmedicine.org/health/conditions-and-diseases/constipation

22. • Medical treatment - Dafflon, Annusol sup, Lidnocaine gel, Lactulose

23. Screening (CRC)
• Average Risk Population
Population with no known risk for CRC.
There is no retrievable evidence on the age to start CRC screening for average risk
population.
• Moderate and High Risk Groups
Family history is a well-established risk factor for CRC.
It is affected by first-, second- and third-degree relatives, and might include positive
family history from both parents.
CPG 2017 - Colorectal Carcinoma

24. CPG 2017 - Colorectal Carcinoma

25. CPG 2017 - Colorectal Carcinoma

26. Referral to Surgical Unit
• Red flag symptoms / malignancy symptoms
• Haemorrhoid grade 3 & 4
• Complicated haemorrhoids

27. THANK YOU