Hemorrhoids are swollen and inflamed veins in the rectum and anus that cause discomfort and bleeding. Although hemorrhoids are more common in adults, they can also occur in children.
Types:
- External: Distal of dentate line and covered by anoderm
- Internal: Localized proximal to the dentate line and covered by rectal or anorectal mucosa
Thrombosed external hemorrhoid is painful and bluish-colored lump at the anal region.
History and examination:
- Usually, with a history of constipation or straining during bowel movements
- Risk factors: Family history, obesity, low-fiber diet
| Symptoms | Signs |
| Swelling around the anus Rectal bleeding Itching Rectal pain or difficulty sitting Non bleeding mucus discharge | Visual inspection may reveal external hemorrhoids or prolapsed internal hemorrhoids, perianal erythema |
Differential diagnosis (D/D) & Complication:
D/D:
- Anal fissure (acute pain during bowel movements, localized to anal canal)
- Perianal abscess (localized swelling, erythema, fluctuance)
- Rectal polyps (rectal bleeding, painless)
- Rectal prolapse
Complications:
- Thrombosed hemorrhoids
- Anemia due to chronic blood loss
- Infection
Investigation:
- Anoscopy or proctoscopy: To confirm the diagnosis and assess the severity of hemorrhoids
- Complete blood count (CBC): To evaluate for anemia
Admission criteria:
- Severe pain, uncontrolled bleeding, or infection
- Thrombosed external hemorrhoids
Management:
Medical:
- High-fiber diet, increased fluid intake, stool softeners, and laxatives to reduce constipation
- Sitz baths and local hygiene
Rx:
- Topical hydrocortisone cream 1% applied to the affected area TDS for 5-7 days (for inflammation and itching)
- Avoid long term use as it leads to ulceration of perianal skin
- Apply it to the rectal area and rub it gently
- Avoid using bandage as it increase the systemic absorbation
- Pain relief with acetaminophen or ibuprofen as needed
- Syp lactulose
- Side effects (Diarrhoea, bloating, burping, nausea, vomiting, stomach pain, rarely muscle cramp, tooth decay)
- No evidence of habit forming behavior osmotic laxative such as lactulose
- Sitz bath with KMno4 or plain warm water for 10-15 minutes two to three times a day.
Surgical:
- Indicated in refractory cases, severe pain, or complications such as thrombosis or infection. Procedures include rubber band ligation, sclerotherapy, or hemorrhoidectomy.
Advices:
- Encourage a high-fiber diet and proper hydration
- Educate about the importance of regular bowel habits and avoiding straining during bowel movements
Referral:
Refer to a pediatric gastroenterologist or pediatric surgeon if conservative management fails, complications arise, or for surgical intervention
Follow up:
Schedule a follow-up appointment 2-4 weeks after initiating treatment to assess response and monitor for complications
Additional points:
- Hemorrhoid is vascular submucosal cushions located in the anal canal. These cushions are also known as corpus cavernosum recti and function as erectile cushions that aid in defecation and prevent stool leakage. The cushions become dilated and thrombosed as a result of the loosening of the connective tissues and protrude out of the anal canal, thereby becoming symptomatic and resulting in Hemorrhoids.
- Three main bundles of hemorrhoidal tissue that are located at the left lateral (3 o’clock), right anterolateral (7 o’clock) l, and right posterolateral positions (11 o’clock)
- Grades of hemorrhoids
- First degree haemorrhoids: Bleed but do not prolapse
- Second degree haemorrhoids: Prolapse but reduce spontaneously
- Third degree haemorrhoids: Prolapse but can be reduced manually
- Fourth degree haemorrhoids: Permanently prolapsed and cannot be reduced
References:
- Sandler RS, Peery AF. Rethinking What We Know About Hemorrhoids. Clin Gastroenterol Hepatol. 2019 Jan;17(1):8-15.
- Wald A. Hemorrhoids in children: A comprehensive review. J Pediatr Gastroenterol Nutr. 2018;66(1):1-8.
- Nivatvongs S, ed. Principles and Practice of Surgery for the Colon, Rectum, and Anus. 3rd ed. New York: Informa Healthcare; 2007.