Hemorrhoids and Anal Fissures: A Short Photo Essay
External hemorrhoids cause severe throbbing pain of sudden onset. Internal lesions are associated with bleeding, protrusion, fecal soiling, and pruritus.
External hemorrhoids (a single lesion is shown here) are found below the dentate line (the division between squamous epithelium distally and transitional columnar epithelium proximally) and so are covered by skin. Patients experience significant pain when external hemorrhoids are dilated and thrombosed-conditions that stretch the overlying skin.
Photo courtesy of Allen P. Kong, MD and Michael J. Stamos, MD.
If a patient's pain is severe at evaluation and there is ulceration, surgical excision (pictured here) can provide relief. Locally anesthetize the hemorrhoid, make an elliptical incision, and evacuate the clot or, preferably, excise the hemorrhoid. The remaining wound can be left open or closed loosely with 4-0 chromic gut suture.
Photo courtesy of Allen P. Kong, MD and Michael J. Stamos, MD.
Internal hemorrhoids (example shown here) are located above the dentate line and appear as a swelling that arises from the anal mucosa. An anoscope may be required to visualize internal hemorrhoids that do not prolapse during examination. Pain is rare but symptoms may include bleeding, protrusion, fecal soiling, and itching. Internal hemorrhoids often coexist with external hemorrhoids.
Photo courtesy of Allen P. Kong, MD and Michael J. Stamos, MD.
Initial treatment for internal hemorrhoids is conservative (psyllium or other bulking agents, avoidance of straining, and decreased toilet time). Invasive therapy is indicated in patients for whom conservative management fails or who cannot tolerate symptoms. Grade 1 hemorrhoids are rarely symptomatic but may be effectively treated with injection sclerotherapy or rubber band ligation. Grade 2 and grade 3 hemorrhoids can be treated in the office with rubber band ligation, shown here.
Photos courtesy of Allen P. Kong, MD and Michael J. Stamos, MD.
Anal fissures are linear ulcerations of the distal anal canal anoderm, as seen here. The majority of fissures appear as anodermal defects located in the posterior midline, although 10% of women and 1% of men have anterior fissures. An associated "sentinel pile" or sentinel skin tag can often be seen at the distal or caudal extent of the fissure.
Photo courtesy of Allen P. Kong, MD and Michael J. Stamos, MD.
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