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Basics

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Author:

Julia H.Sone


Description!!navigator!!

Etiology!!navigator!!

Diagnosis

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Signs and Symptoms!!navigator!!

History

  • Length of bleeding
  • Associate pain
  • New lumps or masses by rectum
  • Stool consistency: Hard or liquid
  • Previous history of rectal problems
  • Stool caliber

Physical Exam

  • Exam of perianal area:
    • Gently spread buttocks
    • Discrete, dark blue, tender mass covered with skin: Thrombosed external hemorrhoid:
      • Can have internal component
    • Purplish, tender mucosal covered mass: Prolapsed, strangulated internal hemorrhoid:
      • Usually associated with enlarged, thrombosed external hemorrhoid
    • Have patient bear down to check for prolapsing hemorrhoids
    • Digital rectal exam mand atory to rule out cancer
  • Anoscopy to visualize anal canal:
    • Identify bleeding internal hemorrhoids

Essential Workup!!navigator!!

Detailed history with thorough anorectal exam

Diagnostic Tests & Interpretation!!navigator!!

Lab

  • CBC if history of significant blood loss:
    • Hemoglobin/hematocrit
  • Platelet count
  • PT/PTT/INR if patient on anticoagulants or severe comorbid condition

Differential Diagnosis!!navigator!!

Treatment

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Prehospital!!navigator!!

Establish IV access if severe bleeding

Initial Stabilization/Therapy!!navigator!!

Direct digital pressure to control bleeding

ED Treatment/Procedures!!navigator!!

Pregnancy Prophylaxis
  • Usually become symptomatic in the third trimester and can be treated conservatively
  • Do not use Analpram-HC (class C)

Medication!!navigator!!

Follow-Up

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Disposition!!navigator!!

Admission Criteria

  • Strangulated grade 4 hemorrhoids:
    • Surgical consult for prolapsed, thrombosed internal hemorrhoids
  • Severe anemia with bleeding hemorrhoids
  • Severe bleeding hemorrhoid in pt on anticoagulation or with portal hypertension

Discharge Criteria

Most patients will go home

Issues for Referral

Surgical referral for:

  • Grade 3 or 4 internal hemorrhoids
  • Suspected anorectal or colonic tumors, inflammatory bowel disease, coagulopathy, pregnancy, or immunocompromised

Follow-up Recommendations!!navigator!!

ALERT
All patients with bright red blood per rectum should be referred to GI or colorectal surgery to r/o malignancy

Pearls and Pitfalls

Hemorrhoids are not the only cause of anorectal pain and bleeding. Investigate for other etiologies when indicated

Additional Reading

See Also (Topic, Algorithm, Electronic Media Element)

Anal Fissure

Codes

ICD9

ICD10

SNOMED