Internal hemorrhoid

Background

Internal and external hemorrhoids divided by pectinate (dentate) line

• Pathologic state cccurs when internal or external hemorrhoid plexus become engorged, prolapsed, or thrombosed
• Bleeding is usually limited (surface of stool, on toilet tissue, at end of defecation)
  • Passage of blood clots requires evaluation for colon lesions

Risk Factors

• Constipation and straining at stool
• Frequent diarrhea
• Older age
• IBD

Clinical Features

• Occur proximal to dentate line
• Constant in their location: 2-, 5-, and 9-o'clock positions (when patient viewed prone)
• Not readily palpable; best visualized through anoscope
  • May be palpable when prolapsed or thrombosed
• Painless bleeding
  • Only painful when nonreducible, strangulation of prolapsed hemorrhoid, or thrombosis (these can lead to infection/necrosis)

Differential Diagnosis

Anorectal Disorders

• Anal tags
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Cryptitis
• Anal fissure
• Anal fistula
• Anorectal abscess
• Proctitis
• Rectal prolapse
• Rectal foreign body
• Pruritus ani
• Pilonidal cyst
• Constipation
• Condyloma acuminata
• Anal cancer
• Colorectal tumor
• Pedunculated polyp
• Crohn Disease
• Syphilitic fissure
• GC/Chlamydia

Lower gastrointestinal bleeding

• Upper GI Bleeding
• Diverticular disease
  • Diverticulitis
• Vascular ectasia
• Inflammatory bowel disease
• Infectious colitis
• Mesenteric Ischemia
• Meckel's diverticulum
• Malignancy / polyps
• Hemorrhoids
  • Internal hemorrhoid
  • External hemorrhoid
• Aortoenteric fisulta
• Rectal foreign body
• Rectal ulcer (HIV, Syphilis, STI)
• Anal fissure

Evaluation

Internal hemorrhoid chart

Internal hemorrhoid grades

Grade	Description	Diagram	Picture
I	Luminal protrusion above dentate line No prolapse Painless bleeding
II	Prolapse with spontaneous reduction Prolapse during straining
III	Prolapse requires manual reduction Prolapse during straining
IV	Prolapse—nonreducible Can result in edema and strangulation

Management

• Conservative treatment
  • Indicated for mild to moderate symptomatic patients with grade 1 to grade 3 hemorrhoids
  • Stool softeners (psyllium), high-fiber diet, topical analgesics
  • Avoid laxatives causing liquid stool (can lead to cryptitis and anal sepsis)
  • Sitz bath 15min TID and after each bowel movement (decreases sphincter pressure)
  • Outpatient surgical referral
  • Prolapsed hemorrhoid in patient with minimal symptoms can be manually reduced
• Emergent surgical consultation and intervention is indicated for:
  • Continued and severe bleeding
  • Incarceration and/or strangulation (grade 4 hemorrhoids)
  • Intractable pain

Prolapse

• When prolapse occurs may develop mucous discharge and pruritus ani
  • If prolapse cannot be reduced progressive edema and strangulation may result
  • Other complications: severe bleeding, thrombosis, infarction, gangrene, sepsis

Disposition

• Generally may be discharged (unless need for surgical intervention)

See Also

• Anorectal Disorders
• Hemorrhoids

References

Authors

Ross Donaldson, Michael Holtz, Neil Young, Claire