Hemorrhoids Lecture for USMLE

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Handwritten lecture discussing hemorrhoids for USMLE Step 2 examination. Looking at pathophysiology, causes, sign and symptoms, work up treatment and management. Definition of hemorrhoids is the engorgement of the venous plexus in anal canal. ANATOMY OF THE ANAL CANAL. The dentae or pectinate line this is separated in embryology. Above the pectinate line is derived from endoderm and below is derived from ectoderm. Also the columnar cells are found above pectinate line, and adenocarcionma. Below the pectinate line squamous cells are common and therefore squamous cell carcinoma. Below the pectinate line is painful, while above the pectinate line is not painful. CAUSES or ETIOLOGY Patients with low fiber diets have constipation and increase pressure and cause engorgement. Also constant diarrhea may also cause engorgement. Prolonged lavatory sitting for hours can block the flow around the anal canal. Trauma, and age are also associated. Some secondary pathologies may lead to hemorrhoids. Hypertonic sphincter makes the patient push harder during defecation. Pregnancy and portal hypertension can backup flow and lead to hemorrhoid engorgement. Internal hemorrhoid are found above the dentate or pectinate line, while external hemorrhoids are found below the dentate/pectinate line. INTERNAL HEMORRHOID There are Anal cushions are found in specific areas, the left lower anal cushion, right posterior anal cushion, and Right Anterior Anal Cushion. Therefore internal hemmorrhoid are found in the 3, 7 and 11 oclock position. There may be minor tufts in between. MIXED HEMORRHOID Hemorrhoid which starts off as internal and moves on as internal EXTERNAL HEMORRHOIDS Circumferential veins which can occur everwhere. The biggest problem is thrombosis which can erode the skin and lead to bleeding bright red blood. When it comes chronic that can lead to skin tags and cause hygiene issues. GRADING OF HEMORRHOIDS Grade 1 - hemorrhoids are not bulging out Grade 2- bulging out, but spontaneously regresses Grade 3 - Bulges out and needs to be returned digitally. Grade 4 - Bulges out and can't be returned digitally. External sphincter can strangulate prolapsed hemorrhoid that can lead to fibrosis and grangrene of the prolapsed piece. This piece can ulcerate which leads to bleeding and thrombose which leads to pain. DIAGNOSIS Visual Inspection by placing patient in LLDP. External hemorrhoid is visible right away, absence and fissures. Digital Rectal Exam feel for tone of anal canal, tenderness. Anoscopy will show bulging blue veins. CBC to rule out anemia which is extremely rare. TREATMENT AND MANAGEMENT Conservative in Stage 1 which includes diet and fiber and decrease hematochezia they may have. Pruritus can be treated with cream (hdyrocoritsone) and Sitz bath. Minimally invasive treatment is Rubber Band LIgation for Grade 1, 2, or 3. Laser photocoagulation, sclerotherapy and cryosurgery. Surgery is reserved for stage 3 or 4 and sometimes stage 2. This will be usedful in thrombsosi, bleeding, gangrene. Open or closed hemorrhoidectomy which have a 95% cure rate and infection rate is slow. Stapled hemorrhoidectomy have a high recurrence and low pain/ stay rate.

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