Hemorrhoids
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Management of Hemorrhoids (2024)
Hemorrhoids: The Good, Bad, and Ugly
Anorectal Disease- A 72-year-old man currently on apixaban after recent coronary artery stent placement presents to your office with intermittent rectal bleeding with defecation. He has increased his dietary fiber and water intake. Anoscopy shows grade 2 internal hemorrhoids. What is the best next step in the management of this patient?
- A 40-year-old man presents to your office and reports pain and swelling with the inability to defecate for the last few days. Symptoms started after an episode of constipation where he strained on the toilet for quite some time. On examination, the patient has exquisite tenderness in the perianal area along with other findings, as shown in the image. What is the most appropriate treatment?
- A 28-year-old woman presents in her 36th week of pregnancy with 3 days duration of severe anorectal pain. The pregnancy has been otherwise unremarkable. Vital signs are normal. On examination, circumferential prolapsing, strangulated thrombosed hemorrhoids are seen. The best next step in management is
- A 32-year-old man presented to the emergency department with severe anal pain. Yesterday morning, he had to strain quite forcefully to pass hard, pellet-like stools. Since then he has had persistent and worsening swelling of the tissues in the anal area, which did not resolve with sitz bath. The pain has become severe, and he is unable to rest comfortably in any position. He has normal vital signs, and physical examination is normal except that he has minimally engorged internal hemorrhoids without necrosis, and the external portion in left lateral quadrant is swollen, purple, and is 2 cm in size. The skin is intact and there is no cellulitis. The best option for the patient is
- A 72-year-old with primary sclerosing cholangitis (PSC) is admitted with lower gastrointestinal bleeding that has persisted for 72 hours. Physical examination reveals caput medusa as well as enlarged external hemorrhoids. A diagnostic colonoscopy reveals multiple bleeding submucosal vessels near the anorectal junction. The most appropriate management is
- A 40-year-old undergoes an emergency excisional hemorrhoidectomy for strangulated, prolapsing grade 4 internal hemorrhoids (Figure 1). Eight weeks following surgery, the patient report narrow caliber stools, tenesmus, and constipation (Figure 2). What operative technique could prevent the findings in Figure 2?
- A 34-year-old patient presents with a 2-day history of severe rectal pain, which is constant and not related to bowel movements. On examinaton, the patient has no external hemorrhoids or lesions and you cannot perform a digital rectal examination (DRE) due to extreme pain. What is the most likely diagnosis?
- A healthy 45-year-old male patient presents with constipation and hemorrhoids. Patient reports that after a bowel movement, hemorrhoidal swelling subsides on its own. On perianal examination, there are no external hemorrhoids. Anoscopic exam reveals a large right anterior internal hemorrhoid. What is the first step in management?
- Physical examination of a 45-year-old male patient who has chronic constipation demonstrated enlarged circumferential external hemorrhoids. On vasalva, internal hemorrhoids prolapsed out of the anal canal and had to be manually reduced. The grade of internal hemorrhoids with these clinical findings is
- A 36-year-old patient was diagnosed with Crohn’s disease of the terminal ileum 4 years ago. She is currently in remission on infliximab; however, she is concerned about anal skin outgrowth that is frequently irritated. Physical examination reveals a 1.2-cm round anal skin tag that is soft, nontender with a smooth surface. Anoscopy shows normal appearing anorectal mucosa without evidence of perianal abscess or fistula. The most appropriate next step in management for this patient is
- A 38-year-old patient presents with symptomatic grade 3 internal hemorrhoids. Which of the following is a contraindication to stapled hemorrhoidopexy?
- A 46-year-old man presents to your office with rectal bleeding associated with bowel movements and prolapse of tissue from his anus that spontaneously reduces. Recent colonoscopy demonstrated moderate internal hemorrhoids and a 3-mm tubular adenoma in the sigmoid colon removed with cold forceps. A single rubber band ligation was performed during this procedure. Two days later, he presents to the emergency department with a fever of 102°C, pelvic pain, and urinary retention. The most definitive treatment is
- Patient presents with bleeding per rectum with bowel movements and partial hemorrhoidal prolapse with straining and spontaneous reduction. Patient had a colonoscopy 12 months ago that only showed enlarged hemorrhoids. Patient has been on supplemental fiber for the past 6 months. The best next treatment for this patient’s rectal bleeding is
- A 37-year-old man presented to you with intermittent hemorrhoid bleeding and irritation. He reported a long history of constipation and straining with bowel movements. He has embraced a high fiber diet and increased water intake. Bowel movements are passing well without straining. He still notes large anal tags and intermittent irritation though much less bleeding. His symptoms have not completely resolved. He is interested in additional treatment to reduce symptoms. The best option for him at this time is
- A 65-year-old patient undergoes rubber band ligation of two hemorrhoid columns on the same day in the office. Three days later the patient calls to report extreme anal pain, fevers, and urinary retention. Which of the following is the best next step for this patient?
- A 40-year-old man presents to the emergency department 4 days after band ligation of a grade 2 internal hemorrhoid with a fever and reports of urinary retention. On evaluation, vital signs indicate temperature 102.2 °F, heart rate of 102 beats per minute, and blood pressure of 114/80 mmHg. Laboratory evaluation is significant for a white blood cell count of 17,000. Physical examination reveals significant anorectal tenderness and swelling. Based on these findings, the best next step in management is
Hemorrhoids
Anorectal Disease- A 47-year-old man with chronic constipation presents with increasingly painful prolapsed perianal tissue of 3 days’ duration (Figure) Which of the following is the best next step in treatment?
- A 68-year-old man with end-stage liver disease presents with repeated episodes of lower gastrointestinal bleeding resulting in symptomatic anemia with hypotension. Colonoscopy shows prominent veins in the submucosa of the lower rectum. Which of the following is the most durable treatment option?
- You evaluate a patient with a 3-month history of pruritis ani. Examination reveals perianal erythema and excoriation. You treat the patient with dietary modification and calamine-zinc barrier. The patient returns in 3 months reporting no symptomatic improvement. What is the next step in management?
- An 80-year-old woman presents with anal pruritus and prolapsing internal hemorrhoids. She has fecal urgency and occasional fecal accidents. On anoscopy, grade 2 internal hemorrhoids are visualized. What is the best option for treating her internal hemorrhoids?
- A 28-year-old woman with perianal Crohn’s disease is referred for evaluation for perianal itching. On examination, she has large bilateral anal skin tags that are painless to palpation. What is the most appropriate treatment?
- A 37-year-old homosexual man presents for evaluation for anal bleeding and prolapsing internal hemorrhoids. He reports only transient improvement after several rubber band ligations. On examination, grade III internal hemorrhoids are noted with a minimal external hemorrhoidal component. What is the next step in management?
- A 35-year-old man presents to the office for evaluation for anal itching and an episode of painless rectal bleeding. On examination, he has small hemorrhoidal skin tags. Office anoscopy shows grade I internal hemorrhoids. What is the initial treatment of choice?
- A 29-year-old healthy man presents to the emergency department with severe anal pain and urinary retention 72 hours after hemorrhoidal banding. His temperature is 101.6°F (38.7°C), heart rate is 120 beats/min, and blood pressure is 80/50 mm Hg. His abdomen is mildly tender in the suprapubic region. Urinary catheter was placed and 750 mL of urine drained. What is the best next step in management?
- A 67-year-old patient presents with a 2-year history of recurrent hemorrhoid swelling, difficulty cleaning, and bright red blood with bowel movements despite fiber supplementation and avoidance of straining. Examination reveals grade III hemorrhoids with a large external component. Which of the following would be the most effective treatment?
- A patient presents with difficult and painful evacuation 2 months after undergoing Ferguson excisional hemorrhoidectomy for acutely thrombosed grade IV internal and external hemorrhoids. An examination reveals anal stenosis. What is the most likely cause of the anal stenosis?
- A 55-year-old man presents with multiple perianal and anal canal condylomas. The patient undergoes an examination under anesthesia and excision. Which of the following techniques is most appropriate?
- A healthy 41-year-old man presents to your office complaining of blood on the toilet paper after each bowel movement for the past 6 months. On anoscopy, grade II internal hemorrhoids with stigmata of bleeding are found. Which of the following is the most appropriate management?
- A 72-year-old man with obesity underwent an uneventful outpatient 2-quadrant rubber band ligation for bleeding hemorrhoids 4 days ago. He now reports vague perianal pain. Which additional symptom raises the suspicion for procedure-related sepsis?
- A 55-year-old man presents with malaise, fatigue, inability to urinate, temperature of 102°F (38.8°C) and a heart rate of 115 beats/min 4 days after undergoing rubber band ligation for bleeding internal hemorrhoids. What is the next step in management?
- A 78-year-old man with atrial fibrillation seeks inpatient consultation for persistent bright red blood per rectum. He is hemodynamically stable. After holding anticoagulation, colonoscopy demonstrates internal hemorrhoids with stigmata of bleeding. What is the most appropriate next step in management?
- Mastering Management of Hemorrhoids: Operative and Non-Operative Strategies as well as Post-Operative Troubleshooting
- Pelvic Floor
- A 37-year-old woman with a body mass index of 18 kg/m2 has been experiencing rectal pain for 6 months. She has no rectal bleeding, no family history of colon disease, and no chronic change in bowel habits. Findings of digital rectal examination, anoscopy, and flexible sigmoidoscopy are remarkable for grade 2 internal hemorrhoids and tenderness with manipulation of the coccyx. What is the best next step in management?
- An 80-year-old woman with multiple comorbidities has hemorrhoids and fecal incontinence. On examination, you observe full-thickness rectal prolapse and offer a perineal proctectomy. What additional procedure may improve continence?
- Benign Disease
- A 65-year-old man presents to the emergency department 10 days after colonoscopy that had a significant lower gastrointestinal (GI) bleed. Review of the colonoscopy reports he had grade 3 hemorrhoids, a 20-mm semipedunculated polyp in the ascending colon removed with hot snare, a 8-mm sessile polyp removed in the transverse colon by cold snare, and sigmoid diverticulosis. Computed tomography angiography (CTA) is most likely to demonstrate a blush in the
- A 55-year-old female comes to the office with circumferential internal hemorrhoids that prolapse with bowel movement and need to be manually reduced. These have been present since her vaginal delivery 10 years ago. What is the best next treatment for her prolapse that would minimize her time out from work?
- A 32-year-old female patient with Crohn’s disease presents with anal pain. She takes infliximab. On examination, there are large skin tags with an anal fistula draining pus and a 3 x 3 cm area of localized induration and fluctuance. The best next step in her management is
- A 35-year-old woman is in your office for a consultation for asymptomatic grade 1 internal hemorrhoids, for which you recommended fiber supplementation and conservative measures. At the end of the visit, she also asks when she should get a colonoscopy, because her 40-year-old brother had a recent colonoscopy and was found to have a tubulovillous adenoma; their father was diagnosed with stage II colon cancer at age 49 years. There is no other family history of cancer. The recommendation for her colonoscopy is
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- After months of pelvic physical therapy, a patient returns to the office with the chief complaint of difficulty with defecation. She is found to have a rectocele on examination. What condition should be ruled out prior to recommending rectocele repair?
- A 54-year-old woman presents with reports of rectal and vaginal pain that has been present for at least 4 months. She reports worsened pain with defecation, reports no constipation, and states the pain is also present with prolonged sitting. She mentions that there is always discomfort but these actions exacerbate the pain for several hours. On examination, she has minimal benign appearing skin tags, no anal fissure is present, and digital rectal examination is painful upon palpation of the puborectalis and levator muscles. Magnetic resonance imaging (MRI) of the pelvis and colonoscopy are unremarkable. The most appropriate next step in treatment is to
- A 37-year-old woman presents to the clinic reporting pain in the anal area. She says that the pain is present for at least 30–60 minutes after every time after she completes a bowel movement. Physical examination finds no anal fissure and mild external hemorrhoids. Digital rectal exam reveals a tight anal sphincter and tenderness with traction on the puborectalis muscle. What is the most likely diagnosis?
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