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A 50-year-old man presents with painless bright red rectal bleeding on toilet paper for 6 months. Proctoscopy shows internal haemorrhoids at 3, 7, and 11 o'clock that prolapse on straining and reduce spontaneously.
Questions
a) What is the Goligher grade and the recommended first-line treatment? (2 marks)
Grade II (prolapse that reduces spontaneously). First-line: rubber band ligation plus dietary modification (high fibre, adequate fluids).
b) Why must you exclude colorectal cancer in this patient? (2 marks)
Age over 40 with rectal bleeding — colonoscopy is mandatory. Never assume bleeding is from haemorrhoids without excluding proximal pathology (CRC, polyps).
c) Describe the anatomical basis for painless internal haemorrhoids vs painful external haemorrhoids. (3 marks)
Dentate (pectinate) line is the key landmark. Internal haemorrhoids are above the dentate line — visceral innervation = painless. External haemorrhoids are below the dentate line — somatic innervation = painful when thrombosed. Anal cushions are at 3, 7, and 11 o'clock.
d) What is the management of a thrombosed external haemorrhoid presenting 24 hours after onset? (3 marks)
Excision under local anaesthetic (within 72 hours of onset provides dramatic relief). If presenting after 72 hours, conservative management (NSAIDs, sitz baths, stool softeners) — the pain is already resolving.