Complications
Rectal bleeding is a characteristic feature of symptomatic haemorrhoids. At times the bleeding can be excessive or massive, or may be the aetiology of symptomatic anaemia, especially in patients taking oral anticoagulation medications.[35]
Patients with continuous bleeding or those who develop symptomatic anaemia require early endoscopic evaluation (colonoscopy).[2][13] This evaluation is followed by definitive haemorrhoid treatment after more proximal pathology is eliminated.
Acute thrombosis of a haemorrhoid manifests as the sudden onset of perianal pain and the appearance of a tender nodule adjacent to the anal canal.[1] The thrombosis often follows a period of vigorous activity.
The treatment of an acute thrombosis involves the relief of pain, which is the predominant symptom. Non-surgical treatment consists of warm tub soaks. Mild oral analgesia and stool softeners can be offered.[1] The thrombus will be gradually resorbed over 1 to 2 weeks.
Early surgical de-roofing or excision can be considered when symptoms are severe; this will also result in faster resolution of symptoms.[1][13][28]
Prolapsing haemorrhoidal tissue can become incarcerated and be unable to be reduced into the anal canal, causing severe pain.
The treatment for incarcerated haemorrhoids is traditionally urgent surgical haemorrhoidectomy. Adjuncts to reduce the swelling and to facilitate conservative excision include hyaluronidase injection into the swollen haemorrhoidal tissue.
Considerable risk of some degree of impaired continence, usually to flatus (52%) and liquid stool (40%) has been reported following surgical haemorrhoidectomy.[34] Severe incontinence is rare; women are at greater risk. Grade of haemorrhoids does not appear to influence risk of faecal incontinence. Rubber band ligation was not associated with faecal incontinence in one review.[34] Network meta-analyses suggest that stapled haemorrhoidectomy and open haemorrhoidectomy are associated with the highest risk of bowel incontinence.[23][36]
Clinically disproportionate rectal pain, urinary retention, abdominal pain, and pyrexia are often warning signs.
Technically difficult procedures, high and incomplete staple line with full thickness excision should raise suspicion.
Immunocompromised patients including people with diabetes, those on long-term corticosteroids may be at risk.
Imaging (plain chest x-ray, abdominal x-ray, or computed tomography scan) may reveal free air in the peritoneum or retroperitoneum, and may be diagnostic.
Sepsis can progress rapidly to multi-organ failure and shock, and is often fatal. Survival is dependent on early recognition and immediate intervention with empirical broad-spectrum antibiotic therapy, which should be administered within 1 hour of recognition of suspected sepsis. Urgent surgical evaluation is warranted.
Increased incidence with extensive, circumferential excision. Severe long-standing stenosis is rare.
Meticulous attention to technical details, including preservation of skin bridges in between excised pedicles, should prevent occurrence of stenosis.
Minor fibrotic stenosis is treated by dilation in outpatient clinics followed by self-dilation. Significant stenosis will require surgical correction.
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