Internal hemorrhoid

Background

Anatomy of the anus.

Internal and external hemorrhoids divided by pectinate (dentate) line

• Pathologic state cccurs when internal or external hemorrhoid plexus become engorged, prolapsed, or thrombosed
• Bleeding is usually limited (surface of stool, on toilet tissue, at end of defecation)
  • Passage of blood clots requires evaluation for colon lesions

Risk Factors

• Constipation and straining at stool
• Frequent diarrhea
• Older age
• IBD

Clinical Features

• Occur proximal to dentate line
• Constant in their location: 2-, 5-, and 9-o'clock positions (when patient viewed prone)
• Not readily palpable; best visualized through anoscope
  • May be palpable when prolapsed or thrombosed
• Painless bleeding
  • Only painful when nonreducible, strangulation of prolapsed hemorrhoid, or thrombosis (these can lead to infection/necrosis)

Differential Diagnosis

Anorectal Disorders

• Anal fissure
• Anal fistula
• Anal malignancy
• Anal tags
• Anorectal abscess
• Coccydynia
• Colorectal malignancy
• Condyloma acuminata
• Constipation
• Crohn's disease
• Cryptitis
• GC/Chlamydia
• Fecal impaction
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Levator ani syndrome
• Pedunculated polyp
• Pilonidal cyst
• Proctalgia fugax
• Proctitis
• Pruritus ani
  • Enterobius (pinworms)
• Rectal foreign body
• Rectal prolapse
• Syphilitic fissure

Non-GI Look-a-Likes

• Prostatitis

Undifferentiated lower gastrointestinal bleeding

• Upper GI Bleeding
• Diverticular disease
  • Diverticulosis
  • Diverticulitis
• Vascular ectasia / angiodysplasia
• Inflammatory bowel disease
• Infectious colitis
• Mesenteric Ischemia / ischemic colitis
• Meckel's diverticulum
• Colorectal cancer / polyps
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Aortoenteric fistula
  • Nearly 100% mortality if untreated
  • Consider in patients with gastrointestinal bleeding and known abdominal aortic aneurysms or aortic grafts
• Rectal foreign body
• Rectal ulcer (HIV, Syphilis, STI)
• Anal fissure

Evaluation

Internal hemorrhoid chart

Internal hemorrhoid grades

Grade	Description	Diagram	Picture
I	Luminal protrusion above dentate line No prolapse Painless bleeding
II	Prolapse with spontaneous reduction Prolapse during straining
III	Prolapse requires manual reduction Prolapse during straining
IV	Prolapse—nonreducible Can result in edema and strangulation

Management

• Conservative treatment
  • Indicated for mild to moderate symptomatic patients with grade 1 to grade 3 hemorrhoids
  • Stool softeners (psyllium), high-fiber diet, topical analgesics
  • Avoid laxatives causing liquid stool (can lead to cryptitis and anal sepsis)
  • Sitz bath 15min TID and after each bowel movement (decreases sphincter pressure)
  • Outpatient surgical referral
  • Prolapsed hemorrhoid in patient with minimal symptoms can be manually reduced
• Emergent surgical consultation and intervention is indicated for:
  • Continued and severe bleeding
  • Incarceration and/or strangulation (grade 4 hemorrhoids)
  • Intractable pain

Prolapse

• When prolapse occurs may develop mucous discharge and pruritus ani
  • If prolapse cannot be reduced progressive edema and strangulation may result
  • Other complications: severe bleeding, thrombosis, infarction, gangrene, sepsis

Disposition

• Generally may be discharged (unless need for surgical intervention)

See Also

• Anorectal Disorders
• Hemorrhoids