Internal hemorrhoids are traditionally graded from I to IV based on the extent of

prolapse.

Grading of internal hemorrhoids. (Patients may experience painless bleeding with any
grade.)

internal hemorrhoids are further graded based on their appearance and degree of prolapse, known
as Goligher’s classification: (1) First-degree hemorrhoids (grade I): The anal cushions bleed but
do not prolapse; (2) Second-degree hemorrhoids (grade II): The anal cushions prolapse through
the anus on straining but reduce spontaneously; (3) Third-degree hemorrhoids (grade III): The
anal cushions prolapse through the anus on straining or exertion and require manual replacement
into the anal canal; and (4) Fourth-degree hemorrhoids (grade IV): The prolapse stays out at all
times and is irreducible. Acutely thrombosed, incarcerated internal hemorrhoids and
incarcerated, thrombosed hemorrhoids involving circumferential rectal mucosal prolapse are also
fourth-degree hemorrhoids

PATHOPHYSIOLOGY:

The exact pathophysiology of hemorrhoids development remains unknown, but it is most likely to be

Multifactorial. Constipation was identified to be one of the most important risk factors for hemorrhoids.
Individuals experiencing constipation are more likely to have prolonged and excessive straining together
with passing hard and lumpy stool.

One could be due to genetic predisposition having heredity rectal problems and the other one
could be due to increased intra- abdominal pressure which would eventually cause mechanical
injury to the anal cushions.

The supporting tissue of anal cushions deteriorate.

 The anal cushions of patients with hemorrhoids show significant pathological changes. These
changes include abnormal venous dilatation, vascular thrombosis, degenerative process in the
collagen fibers and fibroelastic tissues, distortion and rupture of the anal subepithelial muscle
(Figure (Figure2).2).

In addition to the above findings, a severe inflammatory reaction involving the vascular wall and
surrounding connective tissue has been demonstrated in hemorrhoidal specimens, with
associated mucosal ulceration, ischemia and thrombosis

Why do hemorrhoids bleed? Straining or passing a particularly hard stool

can damage the surface of a hemorrhoid, causing it to bleed. This can
happen with both internal and external hemorrhoids. In some cases, a
thrombosed hemorrhoid can burst if it becomes too full, resulting in bleeding

Hemorrhoids vs varices - Rectal varices are dilated superior and middle hemorrhoidal veins,
whereas hemorrhoids are dilated vascular channels above the dentate line. Rectal varices
collapse with digital pressure, but hemorrhoids do not.

Rectal varices must be distinguished from hemorrhoids, which represent prolapsed vascular ectatic
vessels or cushions that communicate with the hemorrhoidal plexus. There has been no
documentation of direct connection between hemorrhoids and either the systemic or portal veins.

Rectal varices are portosystemic collaterals that form as a complication of portal hypertension
defined rectal varices as dilated veins that originate more than 4 cm above the anal verge, clearly
distinct from hemorrhoids, and not contiguous with the anal columns and/or pectinate line

Rectal varices are collaterals between the portal and systemic circulations that manifest as a
dilation of the submucosal veins and constitute a pathway for portal venous flow between the
superior rectal veins which branch from the inferior mesenteric system and the middle inferior
rectal veins from the iliac system

CARDIOVASCULAR

Inspection:

No jugular vein distension.

No prominent veins or arteries, no obvious pulsations, no precordial bulge

Nails are not cyanotic

Palpation:

Adynamic precordium. No precordial bulge, pulsations, thrills, or heave noted

Percussion:

Dull upon percussion

Auscultaion:

Normal sinus rhythm

Apex of heart at the 5th intercostal space, left mid-clavicular line

Regular in rate and rhythm. S1 and S2 distinct. No murmurs noted.

ABDOMEN
Inspection:

Abdomen is symmetrical and flat. Left implanted gastric tube for enteral feeding, present
incisional wound, post-removal of staples with staple marks.

Wound assessment: 4inches long, thin vertical incisional wound, no discharges, healing
normally, no redness at the periphery,

No visible scattered veins, scars and striae.

Peristaltic waves are not visible.

Umbilicus at midline and inverted. No discoloration and inflammation noted on the

umbilicus.

Auscultation:

Normoactive bowel sounds normoactive at 3-5 cycles/min.

No bruit, no other abnormal sounds

Percussion:

Dull liver area, non-tender; liver span 8cm at midclavicular line.

Palpation:

Liver is palpable, no masses, smooth soft liver edge, non palpable spleen, no organomegaly,
non-tender on all quadrants
GENITALIA: “Circumcised male. No penile discharge or lesions. No scrotal swelling or discol- oration. Testes
descended bilaterally, smooth, without masses. Epididymis is nontender. No inguinal or femoral hernias.”

Digital rectal examination:no masses, normal colored blood stool

The abdominal examination ends with the digital rectal examination. After explaining the
procedure, taking the patient’s consent, and maintaining the patient’s privacy, the rectal
examination should be performed with the proper technique. The examiner should place his or
her lubricated, gloved finger against the patient’s rectal sphincter muscle to dilate the
sphincter and slowly slide it into the rectum palpating for hemorrhoids, fissures, or foreign
bodies. The prostate for size and firmness should be assessed. Tenderness or bogginess suggests
prostatitis and nodules may suggest cancer. After the finger is removed it should be inspected for
signs of active bleeding or melena. Perform a Guaiac test if bleeding is suspected. Examination
of the external genitalia should also be performed.

Rectal Exam Technique

Positions

There are multiple positions that you can ask your patient to stand or lie. These include:

1. Standing position: patient standing with toes pointing in, then leans over a table
2. Right lateral decubitus (Sims position): patient lies on right side with right hip/leg
straight and the left hip/knee is bent
3. Knee to chest: patient with lying on table facing down with knees up to chest bent
forward

* (Both the standing and knee to chest positions are optimal for the prostate exam)

Inspection of Anus

Look for external hemorrhoids, fissures (90% of time they are located in midline posteriorly),
skin tags, warts or discharge

Palpate Rectum and Prostate

1. Use a small amount of lubricant on the index finger and ask the patient to take a deep
breath and insert the finger facing down (6 o'clock position)
2. Appreciate the external sphincter tone then ask the patient to bear down and feel for
tightening of the sphincter
3. Palpate the prostate gland. Note the following:
a. Approximate size of the prostate gland (normally about the size of a walnut, 2-3
cm but wider at the top)
 b. Feel for tenderness (prostatitis)
c. Feel for nodules or masses
4. Palpate the rectal wall starting from the 6 o'clock position clockwise to the 12 o'clock
position. Then return to the 6 o'clock position and palpate the other half of the rectal wall
feeling for masses, nodules and tenderness.

Occult Blood Test

Check any fecal material for occult blood with a guaiac kit.

LABS:

A normal PT with an abnormal aPTT means that the defect lies within the
intrinsic pathway, and a deficiency of factor VIII, IX, X, or XIII is suggested. A
normal aPTT with an abnormal PT means that the defect lies within the
extrinsic pathway and suggests a possible factor VII deficiency.

Aminotransferases are chemicals that the liver uses to make glycogen. Glycogen is the stored
form of glucose, a sugar that the body uses for energy. Any glucose not immediately used will be
converted into glycogen and stored in cells for future use. Most will be stored in the liver, while
the remainder will be warehoused in skeletal muscles, glial cells of the brain, and other organs.

Aspartate aminotransferase (AST) is found in a variety of tissues, including the liver, brain,
pancreas, heart, kidneys, lungs, and skeletal muscles. If any of these tissues are damaged, AST
will be released into the bloodstream. While increased AST levels are indicative of a tissue
injury, it is not specific to the liver per se.

By contrast, alanine aminotransferase (ALT) is found primarily in the liver. Any elevation of

the ALT is a direct indication of a liver injury, whether minor or severe. Occasional increases
may occur in association with a short-term infection or illness. Sustained increases are more
problematic as they suggest an underlying disease and a greater likelihood of liver damage.

Elevated levels of ALP in the blood are most commonly caused by liver disease, bile
duct obstruction, gallbladder disease, or bone disorders. This test measures the level of
ALP in the blood.