Hemorrhoids  

 

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Ano-Rectal Anatomy

Hemorrhoids

Perianal Abscess

Pilonidal Disease

Fistula-in-Ano

Anal Fissures

 Hemorrhoids

Etiology

Hemorrhoids

Hemorrhoids are a common problem seen in the primary care and ambulatory surgery setting.  Hemorrhoids are actually vascular cushions located within the anal canal.  They occur in three constant positions:  Right Anterior, Right Posterior, and Left Lateral.  Hemorrhoids can be internal (originating above the dentate line), external (originating below the dentate line), or mixed.  Internal hemorrhoids (also known as "piles") are caused by prolapses of rectal mucosa containing the normally dilated veins of the internal venous plexus.  External hemorrhoids are thromboses in the veins of the external rectal venous plexus, and as such are covered by skin.

The major precipitator of hemorrhoids is increased rectal pressure (most often due to straining or constipation).  Other causes of increased pelvic pressure such as pregnancy, portal hypertension, and excessive diarrhea can exacerbate their development as well.

Because of the differing nervous innervation above and below this line, the clinical presentation will differ as well.

Clinical Presentation

The classic presentation of a patient with hemorrhoids is bleeding (typically with defecation).  The bleeding associated with hemorrhoids coats the stool or toilet paper (bright red), whereas the stool is negative for occult blood.  Most cases of hemorrhoids are painless, unless there is subsequent thrombosis or ulceration.  In fact, although patients may complain of burning or itching, the fact is that hemorrhoids, themselves, do not itch or burn.  It is the perianal skin which is the site of pruritis, and is typically the result of poor hygiene in that area (perhaps secondary to pain with cleaning). 

Internal hemorrhoids can be classified into 4 grades:

There is no classification for external hemorrhoids. 

Treatment

Hemorrhoid Treatment

Treatment of hemorrhoids is based on the severity of symptoms and degree of disease (as above).  For asymptomatic disease, conservative management will usually suffice.  Bulk-forming agents, the avoidance of constipation, and sitz baths will typically eradicate the problem, or lessen symptoms.  Accordingly, first degree, asymptomatic hemorrhoids are treated in this manner.  With symptomatic disease, rubber-band ligation or infrared coagulation may be tried.  Sclerotherapy (an older therapy), has largely been abandoned.  In the banding procedure, a small rubber-band is placed around the base of the hemorrhoid, causing the tissue to die and fall off as a result of lack of blood flow.  Likewise, this banding procedure is helpful for second and third degree hemorrhoids as well.

Surgery (in the form of hemorrhoidectomy) is typically reserved for fourth degree hemorrhoids (or some mixed third degree's with a large external component).  In these instances, the large vein is removed and gauze packing is inserted to control bleeding.  The outcome following surgery is very good in the majority of cases, and the patient should be encouraged to adhere to a high fiber diet and avoid constipation in order to avoid recurrence.  In terms of convalescence, patients may experience considerable pain after surgery as the anus tightens and relaxes, but complete recovery is usually seen within two weeks.

External hemorrhoids typically do not cause many problems.  Excision is typically reserved for very large hemorrhoids which interfere with good perianal hygiene.  Occasionally, patients may present with severe perianal pain and a lump near the anus following severe constipation or prolonged sitting.  Visual or rectal exam may reveal a thrombosed external hemorrhoid.  A thrombosed external hemorrhoid is one in which blood has pooled and formed a clot. This type of hemorrhoid occurs outside the rectum, around the anal region. It will usually appear as bulging, purple or bluish skin-covered veins, or can be reddish when inflamed. To the touch, it usually feels like a small, hard lump, roughly the size of a pea.  With this type of hemorrhoid, most sufferers experience some degree of pain, often quite a lot. A thrombosed external hemorrhoid can cause swelling, itching and/or pain, but it will almost never bleed. The usual treatment is drainage or removal of the clot or the entire hemorrhoid, but only if the condition is acute (<72 hours).  Otherwise, expectant management and a high fiber diet is typically all that is needed, as the problem is usually self-limited over 7-10 days.