Chapter 19-8: Hemorrhoidal Bleeding

TEXTBOOK PRESENTATION

Hemorrhoidal bleeding typically presents with rectal pain and bleeding. The pain is worst with bowel movements, straining, or sitting. Occasionally, hemorrhoids can present with painless bleeding.

DISEASE HIGHLIGHTS

1. Hemorrhoids are generally classified as external or internal.

   1. External hemorrhoids

      1. Occur below the dentate line.

      2. Present either as painless bleeding or with engorged, painful, swollen perianal tissue; or with thrombosis. Thrombosed hemorrhoids are purple, extremely painful, and may bleed.

   2. Internal hemorrhoids

      1. Occur above the dentate line.

      2. Symptoms can be a feeling of internal fullness, painless bleeding, or prolapse. Prolapse is usually painful and sometimes associated with bleeding.

   3. Both internal and external hemorrhoids are most symptomatic when sitting, straining, and with constipation.

   4. Bleeding occurs during defecation and commonly is seen on toilet paper when wiping.

A clinician should always verify a patient’s self-diagnosis of hemorrhoids. Many patients refer to all perianal symptoms as hemorrhoids.

EVIDENCE-BASED DIAGNOSIS

1. Hemorrhoidal bleeding is diagnosed by direct observation.

   1. This may be accomplished visually in patients with external hemorrhoids.

   2. Patients with internal hemorrhoids require anoscopy to see hemorrhoids.

2. An important question is “When does benign sounding anorectal bleeding need a more extensive evaluation than an anal exam with or without anoscopy?”

   1. One study looked at 201 patients whose review of symptoms revealed rectal bleeding.

      1. 24% of these patients were found to have serious disease. The diseases were polyps (13%), colon cancer (6.5%), and IBD (4%).

      2. Factors associated with risk of serious disease were age, short duration of bleeding, and blood mixed with stool.

      3. No cancers were found in patients younger than 50.

      4. 6 of the 37 patients who had a clear source of anorectal bleeding (fissures or hemorrhoids) also had polyps or cancer.

   2. Another study found only 10 polyps among 314 patients under 40 with rectal bleeding compared with 27 polyps and 1 case of cancer among 256 patients between the ages of 40 and 50.

3. In general, if a young patient (under age 40) with rectal bleeding does not have a clear anorectal source or if the bleeding continues despite treatment of the anorectal source, a more complete evaluation (with colonoscopy) should be done. Patients over 40 should always be evaluated.

   Although serious disease is rare among young people with rectal bleeding, it does occur.

TREATMENT

1. Most hemorrhoids and anal fissures can be treated conservatively with general recommendations for perianal well being.

   1. Sitz baths to relax anal sphincter.

   2. Analgesia with acetaminophen, topical creams, or short-term topical corticosteroids. A doughnut cushion is sometimes helpful for prolonged sitting.

   3. Soften stool with increased fluid intake, a high-fiber diet, and docusate sodium or mineral oil.

   4. Avoid anything that may lead to constipation.

   5. Avoid prolonged sitting, especially on the toilet.

2. Internal hemorrhoids that prolapse or continue to bleed usually require surgical removal.

3. Thrombosed, irreducible internal hemorrhoids and thrombosed external hemorrhoids require rapid surgical treatment.