External hemorrhoids below the dentate line are:
Correct Answer: Painful
Description: Ans. a. Painful (Ref: Sabiston 19/e p1387-1391; Schwartz 9/e p1057-1059; Bailey 26/e p1250-1257, 25/e p1253-1259; Schackelford 7/e p1896-1906)External hemorrhoids are located below dentate line and are painful.External Hemorrhoids:Located distal to dentate lineQAlso known as 5-days painful self curing lesionPainful, not ligatedQExcision is doneQRepeated thrombosis leads to semi-ripe black current appearanceHemorrhoidRecent theories regard hemorrhoids as normal anatomical structuresQ.These are cushions of submucosal tissue containing venules, arterioles, smooth muscle fibres and elastic connective tissue.Three hemorrhoidal cushions are found in the left lateral, right anterior and right posterior position (3, 7 and 11 O' Clock)QHemorrhoids or piles are symptomatic anal cushionsMore common when intra-abdominal pressure is raised, e.g. in obesity, constipation and pregnancySymptoms: bright-red, painless bleeding, mucus discharge and prolapseHemorrhoids cannot be palpated, best diagnosed by proctoscopyQ.Internal HemorrhoidsExternal Hemorrhoids* Located proximal to the dentate lineQ* Painless, can be ligatedQ* Banding is preferredQ* Located distal to dentate lineQ* Also known as 5-days painful self curing lesion* Painful, not ligatedQ* Excision is doneQ* Repeated thrombosis leads to semi-ripe black current appearanceQ Classification of Internal hemorrhoids1st degreePainless bleedingQ, no prolapse2nd degreeProlapse through the anus, on straining but reduce spontaneouslyQ3rd degreeProlapse through the anal canal and require manual reductionQ4th degreePermanently prolapsed and cannot be manually reduced.QTreatment:Mere presence of hemorrhoids is not necessarily an indication of treatment.Treatment is only indicated if they are symptomatic. Best treatment is the least invasive one which is possible to alleviate the symptomsQ.Treatment of hemorrhoidsMedical therapy* Bleeding from 1st and 2nd degree hemorrhoids often improve with the addition of dietary fibre, stool softeners and other diet regulationQ.Rubber band ligation* Done for 1st, 2nd and selected 3rd degree hemorrhoidsQInfrared Photocoagulation* Done for 1st and 2nd degree hemorrhoidsSclerotherapy* Done for 1+, 2nd and selected 3rd degree hemorrhoidsQ* Most commonly used sclerosant is 5% phenol in almond or arachis oil.OperativehemorrhoidectomyQ* 3rd and 4th degree hemorrhoidQ* 2nd degree not cured by non-operative methodsQ* Mixed (combine internal/external hemorrhoids)Q* Fibrosed hemorrhoidsOperative HemorrhoidectomyMilligan-Morgan open hemorrhoidectomyQFerguson closed hemorrhoidectomyQWhitefield submucosal hemorrhoidectomyQLonga's stapler hemorrhoidectomyQ
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