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Internal hemorrhoids are masses of vascular tissue covered by rectal mucosa. They arise from the superior hemorrhoidal plexus and lie above the pectinate line (eFigs. 416.1 and 416.2). External hemorrhoids arise from the inferior hemorrhoidal veins lying below the pectinate line and are covered by skin (eFig. 416.3). Hemorrhoids are rare in children and are usually external, associated with chronic constipation.1 When engorged by straining, they appear as pearly gray or purple masses at the anal verge that occasionally bleed a small amount. They may become firm and painful when thrombosed or infected, conditions more common in adolescence than infancy. Hemorrhoids may be a sign of childhood sexual abuse. Symptoms from hemorrhoids usually improve with treatment of underlying constipation. Incision and evacuation of thrombosed or infected hemorrhoids may be necessary, but stool softeners, warm sitz baths, and antibiotics are often sufficient therapy.

eFigure 416.1

Common sites of hemorrhoids. A: Internal hemorroids at 2, 5, and 9 o’clock. B: Protrusion of anal cushions.

(From Tintinalli JE, Kelen GD, Stapczynski JS. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, McGraw-Hill, 2004.)


eFigure 416.2

Internal Hemorrhoids. Internal hemorrhoids are seen in this endoscopic view of the rectum.

(From Knoop, KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas of Emergency Medicine. 3rd ed. New York: McGraw-Hill, 2010.)

eFigure 416.3

External Thrombosed Hemorrhoids. Typical appearance of acute thrombosed hemorrhoids.

(From Knoop KJ, Stack LB, Storrow AB, Thurman RJ. The Atlas of Emergency Medicine. 3rd ed. New York: McGraw-Hill, 2010. Photo contributor: Lawrence B. Stack, MD.)

Anorectal varices are found beneath the rectal mucosa or in the anal canal. These high-pressure venous channels shunt blood from the portal venous circulation (ie, superior hemorrhoidal vein) to the systemic circulation (ie, external iliac vein) in response to portal hypertension. One third of children with portal hypertension have hemorrhoids, 35% have anorectal varices, and 15% have isolated external anal varices. Occurrence is related to the duration and severity of portal hypertension.2 Rectal varices occasionally cause bleeding, but other symptoms are rare. Injection sclerotherapy or banding of varices is occasionally required in patients with severe portal hypertension and bleeding.

Prolapse is the protrusion of one or all layers of the rectum through the anus.3 Isolated mucosal prolapse is common and appears as a red-purple, cylindrical protrusion from the anus of variable length, with radial folds extending from a central lumen at the leading point. Prolapsed mucosa may bleed and may secrete copious mucus. Anal pain may result from anal sphincter spasm. Children often complain of a mass in the anus after defecation that they cannot expel. Transient minor prolapse of rectal mucosa is common after defecation. Prolapse that includes mucosal, ...

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