---

DMSF IMD 27 - Anal Mass Case Discussion

---

👤 Presenter: Pranav — Intro, History & Physical Exam

History of Present Illness

• 50/M presenting with an anal mass
• 5 years prior to consultation (PTC): Intermittent, painless bright-red rectal bleeding - minimal (~2-3 drops), occurring once every 1-3 months
• 1 year PTC: Noticed a prolapsing anal mass upon straining - manually reducible
• 4 days ago: Sudden onset perianal pain (NRS 7/10) associated with the anal mass, worsening with defecation. Took pain medications
• Current (in-interim): Pain decreased to NRS 1/10

Associated Symptoms

• (+) Constipation - BM every 2-3 days, hard stools
• (+) Straining during defecation
• (-) Weight loss, change in stool caliber, abdominal pain, melena

Past Medical History

• Hypertension - on Amlodipine 5 mg OD
• No prior surgeries

Family History

• Father: Hypertension
• Mother: Type 2 Diabetes Mellitus

Personal & Social History

• Low fiber/fruit/vegetable intake
• Drinks < 2L water/day
• Virtual assistant (sedentary occupation)
• Non-smoker, occasional alcohol drinker

Physical Examination

• General: Alert, oriented
• HEENT: Pink palpebral conjunctivae, anicteric sclerae
• Chest: Distinct heart sounds, clear breath sounds
• Abdomen: Soft, nontender, nondistended, normoactive bowel sounds, no palpable mass

Anorectal Exam

• Visual Inspection (Relaxed): Firm, slightly tender, bluish-purple nodule (~1.5 cm) at the anal verge - right posterolateral area
• Valsalva Maneuver: Bearing down reveals prolapse of pink, engorged mucosal tissue
• DRE: Normal resting sphincter tone; no palpable rectal masses, strictures, or fluctuance; prostate smooth and mildly enlarged

---

🔍 Presenter: Jeni — Primary Impression with Rationale

Primary Impression: Mixed Hemorrhoidal Disease (Thrombosed External Hemorrhoid + Prolapsed Internal Hemorrhoid)

---

📋 Presenter: Vignesh — Differential Diagnoses

Note: At age 50 with rectal bleeding, colorectal malignancy must be excluded. Colonoscopy is indicated.

---

🔬 Presenter: Kashmira — Diagnostic Plan

Bedside/Immediate

Laboratory (Already Available)

Endoscopy

---

✅ Presenter: Avadhat — Final Diagnosis

Mixed Hemorrhoidal Disease

• Thrombosed External Hemorrhoid (right posterolateral, ~1.5 cm, acutely thrombosed with resolving symptoms)
• Internal Hemorrhoid - Grade III (prolapsing on straining, manually reducible, with history of painless rectal bleeding)

• Painless bleeding (5 yrs) = internal hemorrhoid component
• Prolapse requiring manual reduction = Grade III internal hemorrhoid
• Acute bluish-purple tender nodule at anal verge = thrombosed external hemorrhoid
• Current improvement in pain = thrombosis past its peak (>72 hrs), now resolving
• Normal WBC, no fever, no fluctuance = no abscess/sepsis

---

🫀 Presenter: Avinash — Anatomy

Key Anatomical Landmarks

Hemorrhoidal Blood Supply

• Superior hemorrhoidal artery - branch of inferior mesenteric artery (IMA) → internal hemorrhoids
• Middle hemorrhoidal artery - from internal iliac artery
• Inferior hemorrhoidal artery - from internal pudendal artery → external hemorrhoids

Venous Drainage

• Superior hemorrhoidal veins → portal system (clinically important in portal hypertension)
• Inferior hemorrhoidal veins → caval system
• This creates a portosystemic anastomosis at the anorectal junction

Innervation

• Above dentate line: Autonomic (visceral) - no pain fibers → internal hemorrhoids painless
• Below dentate line: Somatic (pudendal nerve S2-S4) → external hemorrhoids exquisitely painful

Classic Hemorrhoid Positions

---

⚙️ Presenter: Keshav — Pathophysiology

Normal Function

How Hemorrhoids Become Symptomatic

1. Vascular Engorgement Theory

2. Sliding Anal Lining Theory (more accepted)

Thrombosis of External Hemorrhoid (This Patient)

• Acute increase in venous pressure (straining/defecation) → rupture of a vein in the external hemorrhoidal plexus → blood clot forms within the subcutaneous tissue below the dentate line
• Result: Acute, painful, firm, bluish-purple nodule
• Covered by anoderm (somatic pain fibers) → severe pain at onset (NRS 7/10)
• Natural history: Peak pain at 48-72 hours → clot begins to organize and reabsorb → pain diminishes over 7-10 days (explains NRS 1/10 now)

Risk Factors in This Patient

---

📊 Presenter: Pragati — Grading

Internal Hemorrhoids: Goligher Classification

This patient has Grade III internal hemorrhoids - the prolapsed mucosal tissue reduced manually.

External Hemorrhoids: No Formal Grading Scale

• Non-thrombosed: Soft, asymptomatic or mildly symptomatic folds
• Thrombosed: Acute, firm, tender, bluish-purple nodule (present in this case)
• Gangrenous: Rare, associated with severe edema and necrosis (not present)

Mixed Hemorrhoids

---

💊 Presenter: Sanya — Management

Acute Management (ED/OPD - This Presentation)

WASH Regimen (Rosen's Emergency Medicine)

Topical Agents

• Topical hydrocortisone cream for short-term (<5 days) to reduce edema and inflammation
• Topical anesthetics (lidocaine 5% ointment) for symptomatic relief
• Witch hazel astringent pads for hygiene

Lifestyle Modifications

• Increase dietary fiber and water intake
• Avoid prolonged sitting/straining
• Regular light exercise to improve perineal tone and venous return

Outpatient Follow-up Management for Grade III Internal Hemorrhoid

Per ASCRS 2024 guidelines: Office-based procedures (especially rubber band ligation) are recommended for most Grade I-II and selected Grade III hemorrhoids.

---

🔪 Surgical Options (Sanya - if applicable)

• Grade III hemorrhoids fail conservative therapy + office procedures
• Grade IV hemorrhoids
• Mixed internal/external hemorrhoids with large external component
• Patient preference
• Complicated disease (thrombosis, strangulation, gangrenous hemorrhoids)

Surgical Options

For THIS patient: Given Grade III disease with mixed hemorrhoid (thrombosed external now resolving), the algorithm would be:

1. Conservative management now (WASH + lifestyle)
2. Rubber band ligation for the internal Grade III component at follow-up visit
3. If RBL fails or recurs → excisional hemorrhoidectomy (Ferguson or Milligan-Morgan)

---

🏥 Presenter: Poornema — Post-Surgical Approach

Immediate Post-Operative Period (Day 0-1)

Days 1-14

Discharge Instructions & Follow-up

Potential Post-Operative Complications

---

📎 Summary Table

---

✅ Confirmations

• Acute onset perianal pain
• Firm, tender, bluish-purple nodule at the anal verge
• Located below the dentate line (external plexus)

• Painless bright-red rectal bleeding for 5 years (internal plexus, above dentate line, no somatic innervation)
• Prolapse on straining requiring manual reduction → this is the defining criterion that separates Grade III from Grade II (which reduces spontaneously)

---

🔧 One Nuance Worth Noting

The thrombosed external hemorrhoid reached peak pain at 48-72 hours (4 days ago was onset), so by presentation the clot has begun to organize and fibrose - pain naturally subsides. This is NOT because the thrombosis has resolved entirely; the nodule is still palpable and visible. It matters for management because:

• If the patient had come within 48-72 hours of onset (NRS 7/10) → early surgical excision would have been preferred
• Now, at >72 hours with declining pain → conservative (WASH) management is appropriate
• If pain were still severe despite the timeline, excision remains an option at any point

---

🔎 One Addition for Completeness

• Valsalva maneuver showing pink, engorged mucosal prolapse - this directly demonstrates the internal hemorrhoid component. The pink columnar mucosa prolapsing is distinct from the bluish-purple external nodule, confirming two separate pathological components contributing to the mixed disease.
• DRE showing no palpable rectal mass - helps exclude a rectal neoplasm as a contributing cause of the bleeding, though colonoscopy is still warranted given his age (50) and 5-year bleeding history.

---

Summary Verdict