hemorrhoid

Patient, a 52 years old gentleman with no known medical illness presented in Hospital X 3 days ago with irreducible per rectal mass during defecation. This was a referred case from KK Y.

History went back to about 3 years ago, patient started to notice a soft mass came out on defecation. It was initially reducible digitally and painless. It was also associated with tenesmus and occasional per rectal bleeding especially when he had constipation. He described the blood as bright red, separated from his stool and seen as streak of blood on the stool. Sometimes in few episodes patient claimed to see the blood dripping on the toilet bowl, and bloody residue left on anal. He quantified each episode of bleeding as 2 spoonful of fresh blood. However he denied any itchiness, blood spot on his undergarment and no discharge of mucus. Each episode was not preceded by trauma.

Over these three years, he has been seeking treatment from a private clinic in his town a few times. He was given a few medications, which was told to soften his stool, to increase his Hb, and suppository to stop the bleeding. His blood was taken each visit for investigation and no other investigation was done. Sometimes, he bought medication from local pharmacy as prescribed by GP. He was also advised by the doctor to regularly consume green vegetables, seafoods, meats, and fibres. He was compliant to the prescription and advice. Condition seems to improved after each episode when he used the medication on breakthrough. He reported that the last bleeding was a month ago.

However a day before admission, he started to develop anemic symptoms such as lethargy, dizziness, palpitation and shortness of breath on exertion when he came home. On passing motion, he claimed that the mass was no longer reducible and associated with pain. Pain was described as pricking in nature, intensity 4-5/10. It was not radiating elsewhere, limited to the mass.  It was more painful when touched with no specific relieving factor.

He denied fever, vomiting, nausea and changes in bowel habit: constipation and diarrhea. Normal bowel output. There was no loss of appetite and loss of weight. There was no similar history in his family.

He then went to klinik kesihatan Y with his wife. Blood was taken but he was unsure of the result of investigation. He is then referred to Hospital X for further management and investigation and was transfused with 2 pints of blood on admission.

He is not known to have any medical illness such as HPT, DM, heart or renal failure,or hematological disorder. He was never been hospitalized or undergone any surgery before. Apart from the medications he has been taking over the 3 years, there was no other regular medication.

He is the eldest out of 5 siblings. His father died at the age of 58 due to renal problem and his mother is still alive, diagnosed with HPT. There was no history of malignancy in his family. He is a father of 8 children. He is self-employed married to acook. The total income was claimed to be adequate for basic necesseties. He denied alcohol consumption and do not smoke.

Upon clerking, the patient was lying in left lateral position with the head of the bed propped up to 45 degree. There was a branula attached on to the dorsum of his left hand but upon clerking, patient wasn’t having any intravenous infusion. He was alert and conscious, was not in pain and not tachypneic. Generally, the patient was pale (as seen on his hand and conjunctiva). The haydrational and nutritional status was fair. There was no cyanosis, finger clubbing, angular stomatitis or pitting edema of both legs. No gum bleeding. There was a BCG scar.

The vital signs are as follows:

            Temperature: 37 degree celcius.

            Blood pressure: 130/80 mmHg.

            Heart rate: 80 beats per minute, good volume.

            Respiratory rate: 20 per minute.

There was no parasternal heave or thrill. First and second heart sound were heard with no murmur. Vocal fremitus was equal and normal bilaterally. Percussion note was normal.Vocal resonance was normal and equal bilaterally. Vesicular breath sound was heard. No basal crepitation was heard.

Abdomen was soft and distended. There was no area of tenderness or guarding. The liver or spleen were not palpable. Liver span around 13cm. Kidneys were not ballotable and no palpable mass. Abdominal auscultation revealed normal bowel sounds, occurring 4-5 times in one minute.

On anal examination, there was a purplish mass observed to have prolapsed from within the anus but I couldn’t spescify the position because it looked as if as the whole circumference of anal margin are swollen(edematous) and erythematous. There was no fissure, ulcer, rashes, scratchmark or active bleeding seen from inside the anus, anal margin or the perianal skin. There was no discharge of mucus. On palpation, the mass was warm, tender and irreducible with fingers. Hence I couldn’t proceed with per rectal examination on this patient.

Provisional

1. Hemorrhoid (acute thrombosed hemorrhoid)

Ddxes

1. perianal hematoma

2. anal fissure

3. abcess

4. perianal tumor
5. anal polyp


In understanding hemorrhoid, it is very crucial to grab the anatomy of the anal canal, hence giving a clear picture of pathogenesis behind it together with the complications. I would suggest for more reading from Burkitt and it is important to cover all the common anal symptoms, the classification and priciple of management and the other anal or perianal disorders.

Like in this patient, he presented with acute presentation of complicated hemorrhoid.