Hemоrrhоids 1. Bаckgrоund Definition: Dilаted аnd symptomatic venous cushions of the hemorrhoidal plexus in the anal canal. Anatomy: Internal hemorrhoids: Above the dentate line; covered by columnar mucosa; visceral innervation → painless. External hemorrhoids: Below the dentate line; covered by squamous epithelium; somatic innervation → painful when thrombosed. Pathophysiology: Increased venous pressure from straining, constipation, prolonged sitting, pregnancy, portal hypertension, or obesity causes engorgement and prolapse of venous plexus. Epidemiology: Common in adults 45–65 years; prevalence rises with age and constipation. 2. History Internal hemorrhoids: Painless bright red rectal bleeding (on toilet paper or dripping after defecation). Mucosal prolapse or soiling in advanced grades. External hemorrhoids: Painful perianal lump (thrombosis) with acute onset after straining or prolonged sitting. May have pruritus or swelling but typically no bleeding unless ulcerated. Risk factors: Chronic constipation, prolonged sitting, low-fiber diet, pregnancy, portal hypertension, or frequent heavy lifting. 3. Exam Findings Inspection: External: Visible bluish perianal mass if thrombosed. Internal: Not always visible unless prolapsed (use anoscopy). Digital rectal exam: May reveal soft compressible masses or exclude other causes (fissure, abscess, tumor). Anoscopy: Confirms diagnosis and grades internal hemorrhoids: Grade I: No prolapse, bleeds only Grade II: Prolapse with straining, reduces spontaneously Grade III: Prolapse requires manual reduction Grade IV: Irreducible, may thrombose or ulcerate 4. Making the Diagnosis Clinical diagnosis: Based on history and physical exam (inspection, DRE, anoscopy). Exclude other causes of bleeding: Colonoscopy indicated in: Age ≥45 or risk factors for colorectal cancer Iron-deficiency anemia or melena Atypical bleeding (dark stool, mixed blood, systemic symptoms) Laboratory: CBC if chronic bleeding suspected. 5. Management A. Conservative (First-line for most) Dietary fiber supplementation and increased fluids. Avoid prolonged straining; use stool softeners (docusate). Topical therapies: Witch hazel, hydrocortisone, or anesthetic creams for short-term relief. Sitz baths for comfort. B. Office Procedures (Persistent Grade I–III) Rubber band ligation (most effective for internal hemorrhoids). Sclerotherapy or infrared coagulation if not surgical candidates. C. Surgical Management Excisional hemorrhoidectomy: For large Grade III–IV internal hemorrhoids or recurrent thrombosed external hemorrhoids. Thrombosed external hemorrhoid: Excision within 72 hours provides rapid pain relief. D. Prevention High-fiber diet, hydration, prompt defecation, and avoidance of prolonged sitting or straining. Question A 42-year-old man presents with severe anal pain that began suddenly after straining during a bowel movement this morning. He reports mild swelling but no rectal bleeding. Physical examination reveals a tender, bluish perianal nodule below the dentate line. Which of the following is the most appropriate management?
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