Regarding Grading Of Internal Hemorrhoids.

A 37-year-old man with a history of internal hemorrhoids presents as his symptoms have recently flared. He now describes piles which he has to manually reduce following defecation. What grade of hemorrhoids does he have?

A. Grading system does not apply to internal hemorrhoids
B. Grade I
C. Grade II
D. Grade III
E. Grade IV

Answer:
D. Grade III

Discussion:
Hemorrhoids: 
Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3 o'clock, 7'o'clock and 11 o'clock respectively). Haemorrhoids are said to exist when they become enlarged, congested and symptomatic

Clinical features 
 painless rectal bleeding is the most common symptom
 pruritus
 pain: usually not significant unless piles are thrombosed
 soiling may occur with third or forth degree piles

Types of haemorrhoids

External :

•  originate below the dentate line 
•  prone to thrombosis, may be painful 

Internal :

• originate above the dentate line 
• do not generally cause pain 

Grading of internal hemorrhoids:

• Grade I: Do not prolapse out of the anal canal
• Grade II: Prolapse on defecation but reduce spontaneously
• Grade III: Can be manually reduced
• Grade IV: Cannot be reduced

Management :
 soften stools: increase dietary fibre and fluid intake
 topical local anaesthetics and steroids may be used to help symptoms
 outpatient treatments:
 - rubber band ligation is superior to injection
 - sclerotherapy
 surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments
 newer treatments:
 - Doppler guided haemorrhoidal artery ligation,
 - stapled haemorrhoidopexy

Acutely thrombosed external haemorrhoids 
 typically present with significant pain
 examination reveals a purplish, oedematous, tender subcutaneous perianal mass
 if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days