Signs and Symptoms
- Painless, rectal bleeding with defecation
- Blood on stool or toilet paper
- Bright red blood drips into toilet bowel
- Rectal discomfort or pressure
- Severe pain if:
- Internal hemorrhoids prolapse and strangulate
- External thrombosed hemorrhoids
- Pruritus ani
- May also have fissure
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
Detailed history with thorough anorectal exam
Diagnostic Tests & Interpretation
Lab
- CBC if history of significant blood loss:
- Platelet count
- PT/PTT/INR if patient on anticoagulants or severe comorbid condition
Differential Diagnosis
- Rectal prolapse
- Anal fissure
- Perirectal abscess/fistula
- Condyloma acuminate
- Carcinoma or melanoma
Prehospital
Establish IV access if severe bleeding
Initial Stabilization/Therapy
Direct digital pressure to control bleeding
ED Treatment/Procedures
- Conservative therapy for all patients:
- Hot sitz baths for 15-min t.i.d and after each BM
- High-fiber diet - 30 g/d:
- Eat more fresh fruits and vegetables
- Increase bran intake
- 10-12 glasses of water per day
- Stool softeners
- Bulk-forming laxatives
- NSAIDs: Analgesic and antiinflammatory effects
- Excise thrombosed external hemorrhoid if severe pain, <5 d old and clot not resolving:
- Follow with conservative therapy
- Place patient in prone jackknife position or left lateral decubitus and tape buttocks apart
- Infiltrate surrounding skin and underneath clot using 27G needle with lidocaine-containing epinephrine
- Make an elliptical incision to excise clot/skin
- May need silver nitrate sticks for hemostasis
- Place a small piece of Gelfoam and /or gauze onto the wound and tape
- Remove dressing at time of first sitz bath in about 6 hr
- Give analgesics:
- NSAIDs
- Acetaminophen
- Lidocaine 5% ointment to anus: Topical anesthetic for pain relief
- Nitroglycerin 0.2% topical ointment to anus - decreases pain by inhibiting sphincter spasm
- Manually reduce nonthrombosed, prolapsed internal hemorrhoids:
- Follow with conservative therapy
- May need topical anesthetic or anal sphincter block with local anesthesia
- Can sclerose bleeding internal hemorrhoids with 2.5% sodium morrhuate or 3% hypertonic saline
- Can rubber-band ligate 1 or 2 internal hemorrhoids:
- Avoid in immunocompromised patients due to perineal sepsis
- Avoid in patients on anticoagulation
- Nonreducible internal hemorrhoids:
- Nonstrangulated: Conservative management and surgical referral
- Strangulated: Immediate surgical referral for excision
Pregnancy Prophylaxis |
- Usually become symptomatic in the third trimester and can be treated conservatively
- Do not use Analpram-HC (class C)
|
Medication
- Acetaminophen: 325-650 mg (peds: 15 mg/kg) with codeine 15-30 mg (peds: 0.5 mg/kg) PO q4h p.r.n; do not exceed acetaminophen 4 g/24 hr in adults or 75 mg/kg/24 hr in peds
- Bran/fiber: 20 g PO daily
- Docusate sodium (Colace): 50-200 mg (peds: <3 yr, 10-40 mg/d; 3-6 yr, 20-60 mg/d; >6-12 yr, 40-150 mg/d) PO q12h
- ELA-Max 5 (5% lidocaine anorectal cream): Apply to perianal area q4h p.r.n pain (peds: not for <12 yr of age). Caution: Use very small amount; this product contains about 5-g lidocaine/100-g cream and is readily absorbed
- Hydrocortisone/pramoxine topical (Analpram-HC) 1%/1% cream; 2.5%/1% cream/lotion (peds: Same dosing) apply thin amount to area t.i.d-q.i.d
- Hydrocortisone/lidocaine topical (AnaMantle HC) 0.5%/3% cream; 2.5%/3% gel (peds: Not indicated) apply to anal canal b.i.d
- Ibuprofen (Motrin): 400-600 mg (peds: 40 mg/kg/d) PO q6h
- Nitroglycerin 0.2% ointment: Apply to area t.i.d with cotton-tipped applicator
- Psyllium seeds: 1-2 tsp (peds: 0.25-1 tsp/d) PO q24h
Disposition
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
- Colorectal follow up for grade 3 or 4 internal hemorrhoids or suspected tumor
- Primary care follow-up for uncomplicated hemorrhoids
ALERT |
| All patients with bright red blood per rectum should be referred to GI or colorectal surgery to r/o malignancy |
- AchesonAG, ScholefieldJH. Management of hemorrhoids . BMJ. 2008;336(7640):380-383.
- Kaider-PersonO, PersonB, WexnerSD. Hemorrhoidal disease . J Am Coll Surg. 2007; 204(1);102-117.
- LohsiriwatV. Hemorrhoids: From basic pathophysiology to clinical management . World J Gastroenterol. 2012;18(17):1009-1017.
- Lorenzo RiversoS. Hemorrhoids: Diagnosis and current management . Am Surg. 2009;75(8):635-642.
- WexnerSD, PembertonJH, BeckDE, et al., eds. The ASCRS Textbook of Colon and Rectal Surgery. New York: Springer; 2007.
See Also (Topic, Algorithm, Electronic Media Element)
Anal Fissure