questions 3

Hemorrhoids

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Topic updated on 11/14/17 9:17pm

Snap Shot
  •  A 54-year-old female with a history of alcohol abuse presents with complaints of a mass in his anus.
Introduction
  • Engorgement of venous plexus derived from:
    • superior hemorrhoid vein (internal hemorrhoids) 
    • inferior hemorrhoid vein (external hemorrhoids)
  • Predisposing factors include:
    • pregnancy
    • straining at stool
    • constipation
    • cirrhosis with portal hypertension
      • causes anorectal varices not to be confused with hemorrhoids
  • Thrombosed external hemorrhoid
    • not a true hemorrhoid
    • caused by subcutaneous external hemorrhoids of anal canal
  • Classified by degree:
    • 1st degree: does not prolapse
    • 2nd degree: prolapses with defecation, spontaneously reduces
    • 3rd degree: polapses with defecation, requires manual reduction
    • 4th degree: can not be reduced
Presentation
  • Internal hemorrhoids
    • Anal mass / prolapse
    • Bleeding
  • External hemorrhoids (below dentate line)
    • pain
    • itching
    • bleeding
  • Thrombosed external hemorrhoid
    • excruciating pain with history of hemorrhoids
    • bluish elevation of skin
Evaluation
  • Rectal exam, anoscope, sigmoidoscopy  
Treatment
  • Conservative treatment:
    • proper dietary (fiber) and bowel habits
    • sitz bath
    • stool softeners
    • cortisone cream
  • Definitive Treatment
    • banding
    • cryosurgery
    • sclerotherapy
    • laser surgery
    • hemorrhoidectomy for large refractory hemorrhoids
      • contraindicated in Crohns disease
  • Thrombosed external hemorrhoids
    • sitz baths
    • stool softeners
    • or in severe cases excision of skin with evacuation of the thrombus
Prognosis, Prevention, and Complications
  • Exsanguination (may not have signs of external bleeding)
  • Pelvic infection
  • Incontinence
  • Thrombosis
  • Strangulation
  • Ulceration
  • Infection
  • Anal fissures


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Qbank (2 Questions)

TAG
(M2.GI.18) On a routine check-up, a 37-year-old man tells his primary care physician that he has recently noticed bright red blood on the toilet paper when he wipes. He denies any fatigue, decreased exercise tolerance, abdominal pain, or maroon-colored or black, tarry stools. He has no family history of colon cancer. He has never had a colonoscopy. On physical exam, his temperature is 37 C, heart rate 70/min, and blood pressure 120/75 mmHg. He does not have conjunctival pallor. There are no abnormalities on cardiac, pulmonary, and abdominal exams. Rectal exam is negative for bright red blood or occult blood. What is the best next step in the work-up of this patient? Topic Review Topic

1. Order a complete blood count
2. Colonoscopy
3. Reassurance
4. Anoscopy
5. Genetic testing

PREFERRED RESPONSE ▶
TAG
(M2.GI.59) A 25-year-old man with no significant past medical history presents to his primary care provider with complaints of bloody stool. He states that he first noticed bright red blood on the toilet paper two days ago, and has since noticed blood coating his stool. He also states that he has experienced constipation in the past, and that his stool is well-formed. Upon further questioning, he does not report pain with defecation. The patient has no family history of colorectal cancer or inflammatory bowel disease. Vital signs are: BP 90/50 mm Hg, HR 65/min, RR 12/min, and SpO2 100% on room air. Physical exam does not reveal abdominal discomfort. Digital rectal exam is significant for bright red blood. Which of the following is the most likely diagnosis?
Topic Review Topic

1. Ulcerative colitis
2. External hemorrhoids
3. Colorectal cancer
4. Internal hemorrhoids
5. Anal fissures

PREFERRED RESPONSE ▶


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