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SYMPTOMS/ EXAM

■ Internal

■ Painless, bright-red rectal bleeding, mucous discharge, rectal dis-

comfort

■ Characteristically seen at the 2-, 5-, and 12-o’clock positions on prone

patients on anoscopy; see Figure 11.8

■ External

■ Rectal pain if thrombosed or strangulated

■ Can be seen with visual inspection

DIFFERENTIAL

■ Consider inflammatory bowel disease, diverticular disease, anal fissures/

fistulas, rectal prolapse, ulcerative colitis, Crohn disease.

■ Tumors must be ruled out by sigmoidoscopy in all cases of rectal bleeding

in patients >40 years old.

TREATMENT

■ Conservative therapy initially: Manual reduction if uncomplicated; warm

sitz baths, local hygiene, topical analgesics/steroids, bulk laxatives/bran

after the acute phase is treated

■ Surgical referral if needed: Options include rubber band ligation, sclero-

therapy, and excision.

■ External hemorrhoids that have been thrombosed for <48 hours may be

excised in the ED.

COMPLICATIONS

Recurrence, infection, fistula formation, abscess formation, sepsis

Rectal Prolapse

Three types: (1) Rectal mucosa only (usually <2 years old); (2) all layers of

rectum; (3) intussusception through rectum

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES

Left Right

Anterior

Posterior

FIGURE 11.8. Common locations of internal hemmorhoids.

(Reproduced, with permission, from Tintinalli JE, Kelen GD, Stapczynski JS. Emergency

Medicine: A Comprehensive Study Guide, 6th ed. New York: McGraw-Hill, 2004:540.)