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HEMORRHOIDS

Jun 18, 2013

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HEMORRHOIDS. Nga Vu, MD PGY3 Emory Family Medicine 11/18/10. Causes. chronic straining secondary to constipation diarrhea tenesmus long periods trying to defecate common during pregnancy and child-birth . Anatomy.

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• lateral decubitus position
• anal fissures
• medications colchicine
• hydroxyzine hydrochloride
• improve visualization

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HEMORRHOIDS Nga Vu, MD PGY3 Emory Family Medicine 11/18/10

Causes • chronic straining secondary to constipation • diarrhea • tenesmus • long periods trying to defecate • common during pregnancy and child-birth

Anatomy • Dentate line, divides hemorrhoids anatomically into internal (above the junction) and external (below) • external pain fibers end at this point, and most people have no sensation above this line. • Hemorrhoids originating above the junction, are divided into 4 categories depending on the grade of prolapse: • Grade I—Protrudes into the anal canal but does not prolapse • Grade II—Reduces spontaneously • Grade III—Manual reduction • Grade IV—Irreducible prolapse

Symptoms • The most common symptoms of hemorrhoids are bleeding and prolapse. Less frequently, symptoms also include discomfort, pain, soiling, or itching. • Every patient with anorectal symptoms, especially those with rectal bleeding, must have an assessment that includes, at a minimum, digital rectal examination and visual inspection by anoscope

Rectal exam • Left lateral decubitus position for this examination and for almost all anorectal procedures. • Traditional head-down “jackknife” position

Anoscopy • Insert the anoscope • Hemorrhoids appear as pink swellings of the mucosa • Improve visualization • Two prospective studies found that anoscopy detects a higher percentage of lesions in the anorectal region than does flexible sigmoidoscopy (99% vs 78%).

Anoscopy • Even if endoscopic examination includes retroflexion of the scope to inspect the anal canal, optimal visualization is obtained with the Ive's slotted anoscope.

External hemorrhoid after seven days of thrombosis

DDx • anal fissures, pruritus ani, abscess, fistula, and condyloma should be ruled out by examining the anus, the perianal region, and the anal canal

DDx • Anal cancers more commonly cause pain after invasion of the sphincter muscle. • Anorectal pain that begins gradually and becomes excruciating over a few days may indicate infection. • A localized area of tenderness could signal an abscess. • Anal pain accompanied by fever and inability to pass urine signals perineal sepsis and is a medical emergency.

Cancer • Rectal bleeding can mask the diagnosis of cancer. • Elderly • Family or personal history of colorectal cancer • Fatigue, weight loss, palpable tumor, anemia

Pruritis Ani • Systemic illness • Diabetes mellitus • Hyperbilirubinemia • Leukemia • Aplastic anemia • Thyroid

Pruritis Ani • Mechanical factors • Chronic diarrhea/constipation • Soaps, deodorants, perfumes • Prolapsed hemorrhoids • Anal fissure, Anal fistula • Tight-fitting clothes • Allergy

Pruritis Ani • Foods • Tomatoes • Caffeinated beverages • Beer • Citrus products • Milk products • Dermatologic conditions • Psoriasis • Seborrheic dermatitis • Lichen • Erythrasma (Corynebacterium) • Herpes simplex virus Human papillomavirus • Pinworms (Enterobius) • Medications- Colchicine • Quinidine

Chronic Pruritis Ani

Itch/scratch cycle • Antihistamine such as hydroxyzine hydrochloride (Atarax) taken before bedtime • Topical corticosteroids are usually necessary to control pruritus ani but must be limited to short-term use to avoid thinning of the perianal tissues. • Topical 5 percent xylocaine ointment (Lidocaine) can also reduce the itching sensation and break the cycle. • It should be noted that uncomplicated hemorrhoids rarely cause pruritus ani

Fissure • Pain during bowel movements that is described as “being cut with sharp glass” usually indicates a fissure • Bright red rectal bleeding and often begins after a hard, forced bowel movement.

Proctalgia Fugax • Proctalgia fugax is a unique anal pain. Patients with proctalgia fugax experience severe episodes of spasm-like pain that often occur at night • Reassurance, ice, warm water, valium

Constipation • Constipation is regarded as fewer than three bowel movements per week in a person consuming at least 19 g of fiber daily

Fecal impaction • Careful administration of one or two enemas (Fleet) into the bolus to soften and hydrate the stool should be followed one hour afterward by the administration of a mineral oil enema to assist in passage of the softened stool. • Manual disimpaction is required in most patients. After disimpaction, a bowel program that includes the use of a laxative, stool softeners and/or enemas should be initiated to prevent recurrence. If impaction recurs, it is important to rule out an anatomic cause of obstruction such as an anal or rectal stricture or tumor.

Medications • Proctofoam • Hydrocortisone acetate 1% • Pramoxine hydrochloride 1% • Antipruritic, anesthetic • Preparation H • yeast as a live cell derivative (Bio-Dyne: Skin Respiratory Factor) 1% and shark liver oil 3%. • Cooling gel has phenylepherine in addition • Tucks- Anusol • Starch • Lowest potency corticosteroid • Witch Hazel • Tucks medicated pads- astringent

Treatments • Twenty-minute sitz baths (soaking in a tub of warm water) • Anusol or Preparation H to soothe the tissues. • It is very important that your bowel movements remain soft. Drink at least 6 full glasses of water daily. • Take over-the-counter (nonprescription) stool softeners such as Colace or Surfak (2 capsules 2 times a day) • Take a stool-bulking agent such as Metamucil or Citrucel every day. These products can initially produce gas and bloating but can be easier to tolerate if the stool softeners are used simultaneously at the start • Straining at stool should be avoided • Do not sit for long periods on the toilet. Remove all reading materials from the bathroom.

Treatments • Anal stretch, or manual anal dilatation, has been reported to be effective in the treatment of hemorrhoids • SOR B • High-fiber diet or fiber supplements • NNT=2.8 for reduction of rectal bleeding and 3.6 for pain relief

Treatments • SOR A • Office procedures • Rubber band ligation was more effective and required fewer additional treatments for symptomatic recurrence than did infrared coagulation (NNT=9) and sclerotherapy (NNT=6.9); but rubber band ligation produced more complications than did infrared coagulation (pain: NNH=6) • Hemorrhoidectomy • More effective than office procedures, but it is more painful and presents more complications; office procedures are cheaper and require no time off from work • United States, the Ferguson (closed) hemorrhoidectomy is preferred. • Europe is the Milligan-Morgan technique (open). • Stapling technique • As effective as hemorrhoidectomy, is less painful, and requires less time off from work; more long-term data are needed

Treatment • In a small randomized clinical trial, the addition of topical nifedipine (0.3%) to a lidocaine ointment (1.5%) was more effective than lidocaine alone in reducing pain and shortening resolution time.

Prognosis • 90% of patients will not require surgery to alleviate their symptoms (SOR: B)

References • Pablo Alonso-Coello,, MD; Mercè Marzo Castillejo, MD, PhD . “Office evaluation and treatment of hemorrhoids”. Journal of Family Practice. May 2003; Vol 52, No. 5 • JOHN L. PFENNINGER, M.D, GEORGE G. ZAINEA, M.D. “Common Anorectal Conditions: Part I. Symptoms and Complaints”. Am Fam Physician. 2001 Jun 15;63(12):2391-2398. • JOHN L. PFENNINGER, M.D., GEORGE G. ZAINEA. “Common Anorectal Conditions: Part II. Lesions”. Am Fam Physician. 2001 Jul 1;64(1):77-89.

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Hemorrhoids Clinical Presentation

• Author: Kyle R Perry, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
• Sections Hemorrhoids
• Etiology and Pathophysiology
• Epidemiology
• Physical Examination
• Grading of Internal Hemorrhoids
• Approach Considerations
• Hematologic Tests
• Anoscopy and Flexible Sigmoidoscopy
• Other Diagnostic Imaging Studies
• Histologic Features
• Emergency Department Care
• Conservative Management
• Nonsurgical Procedures
• Surgical Intervention
• Long-Term Monitoring
• Medication Summary
• Stool softeners
• Topical anesthetics
• Mild astringent
• Questions & Answers
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Most laypersons and many practitioners attribute all perianal symptoms to hemorrhoids. The astute clinician can often listen to a patient's description of symptoms and ascertain the source of the problem or condition before confirmatory examination. Nonhemorrhoidal causes of symptoms (eg, fissure, abscess, fistula, pruritus ani, condylomata, and viral or bacterial skin infection) need to be excluded.

The most common presentation of hemorrhoids is rectal bleeding, pain, pruritus, or prolapse. Because these symptoms are extremely nonspecific and may be seen in a number of anorectal diseases, the physician must therefore rely on a thorough history to help narrow the differential diagnosis and must perform an adequate physical examination (including anoscopy when indicated) to confirm the diagnosis.

Familial predisposition, diet, a history of constipation or diarrhea, and a history of prolonged sitting or heavy lifting are also relevant, as are weight loss, abdominal pain, or any change in appetite or bowel habits. The presence of pruritus or any discharge should also be noted.

Inflammatory bowel diseases (eg, ulcerative colitis, Crohn disease) need to be ruled out as the cause of symptoms. [ 13 ] Human immunodeficiency virus (HIV) infection and other immunosuppressive diseases can also alter treatment plans.

An adequate history should include a disease-specific history and physical examination, particularly focused on the onset, duration, and degree of the symptoms and risk factors. [ 14 ] In addition to characterizing any pain, bleeding, protrusion, or change in bowel habits, special attention should be placed on the patient's coagulation history and immune status.

Rectal bleeding is the most common presenting symptom. The blood is usually bright red and may drip, squirt into the toilet bowl, or appear as streaks on the toilet paper. The physician should inquire about the quantity, color, and timing of any rectal bleeding. Darker blood or blood mixed with stool should raise suspicion of a more proximal cause of bleeding.

A patient with a thrombosed external hemorrhoid may present with complaints of an acutely painful mass at the rectum (see the image below). Pain truly caused by hemorrhoids usually arises only with acute thrombus formation. This pain peaks at 48-72 hours and begins to decline by the fourth day as the thrombus organizes. New-onset anal pain in the absence of a thrombosed hemorrhoid should prompt investigation for an alternate cause, such as an intersphincteric abscess or anal fissure. As many as 20% of patients with hemorrhoids will have concomitant anal fissures.

The presence, timing, and reducibility of prolapse, when present, will help classify the grade of internal hemorrhoids and guide the therapeutic approach (see Grading of Internal Hemorrhoids ). Grade I internal hemorrhoids are usually asymptomatic but, at times, may cause minimal bleeding. Grades II, III, or IV internal hemorrhoids usually present with painless bleeding but also may present with complaints of a dull aching pain, pruritus, or other symptoms due to prolapse.

In addition to the general physical examination, physicians should also perform visual inspection of the rectum, digital rectal examination, and anoscopy or proctosigmoidoscopy when appropriate.

The preferred position for the digital rectal examination is the left lateral decubitus with the patient's knees flexed toward the chest. Topical anesthetics (eg, 20% benzocaine or 5% lidocaine ointment) may help to reduce any discomfort caused by examination.

Inspect and examine the entire perianal area. Warn the patient before any probing or poking. Because patient apprehension is great before any anal examination, go to great lengths to reassure the patient. Gentle spreading of the buttocks allows easy visualization of most of the anoderm; this includes the distal anal canal. Anal fissures and perianal dermatitis (pruritus ani) are easily visible without internal probing. Note the location and size of skin tags and the presence of thromboses. Normal corrugation of the anoderm and a normal anal wink with stimulation confirms intact sensation.

The following are external findings that are important to note:

Redundant tissue

Skin tags from old thrombosed external hemorrhoids

Signs of infection or abscess formation

Rectal or hemorrhoidal prolapse, appearing as a bluish, tender perianal mass

Digital examination of the anal canal can identify any indurated or ulcerated areas. Also assess for any masses, tenderness, mucoid discharge or blood, and rectal tone. Because internal hemorrhoids are soft vascular structures, they are usually not palpable unless thrombosed.

Guidelines from most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. The American Society of Colon and Rectal Surgeons (ASCRS) recommends complete endoscopic evaluation of the colon in select patients with symptomatic hemorrhoids and rectal bleeding. [ 14 ] Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of hemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination. Other colonoscopic screening criteria include the following patient features [ 14 ] :

• Age 50 years or older, if there hasn't been a complete examination within 10 years
• Age 40 years or older or 10 years younger than the age at diagnosis for a positive history for: (1) a single first-degree relative with colorectal cancer or advanced adenoma diagnosed at younger than 60 years; or (2) two first-degree relatives with colorectal cancer or advanced adenomas
• A positive fecal immunochemical testing (FIT)
• A positive FIT-fecal DNA test

Most clinicians use the grading system proposed by Banov et al in 1985, which classifies internal hemorrhoids by their degree of prolapse into the anal canal. This system both correlates with symptoms and guides therapeutic approaches, as follows.

Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse

Grade II hemorrhoids may protrude beyond the anal verge with straining or defecating but reduce spontaneously when straining ceases (ie, return to their resting point by themselves)

Grade III hemorrhoids protrude spontaneously or with straining and require manual reduction (ie, require manual effort for replacement into the anal canal)

Grade IV hemorrhoids chronically prolapse and cannot be reduced; these lesions usually contain both internal and external components and may present with acute thrombosis or strangulation

Similarly and more simply, the 2018 American Society of Colon and Rectal Surgeons (ASCRS) guidelines for the management of hemorrhoids classify internal hemorrhoids into the following four grades [ 14 ] :

Grade I: Prominent hemorrhoidal vessels, no prolapse

Grade II: Prolapsed hemorrhoids with Valsalva maneuver; spontaneously reduces

Grade III: Prolapsed hemorrhoids with Valsalva maneuver; manual reduction is required

Grade IV: Chronically prolapsed hemorrhoids; manual reduction is ineffective

However, the classification of hemorrhoids continues to evolve, with potential future elements to include prolapse, bleeding, and pain, and may involve considerations of comorbidities and female sex. [ 15 ] One new classification proposes taking into account the following three factors [ 15 , 16 ] :

The evolutionary nature of hemorrhoidal disease (to overcome the internal/external hemorrhoids division; consider prolapse)

The prevalent symptomatology regardless of prolapse grade

The etiopathogenetic and (female) sex aspect

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Ho YH, Cheong WK, Tsang C, et al. Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum . 2000 Dec. 43(12):1666-75. [QxMD MEDLINE Link] .

Senagore AJ, Singer M, Abcarian H, et al. A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results. Dis Colon Rectum . 2004 Nov. 47(11):1824-36. [QxMD MEDLINE Link] .

Behboo R, Zanella S, Ruffolo C, Vafai M, Marino F, Scarpa M. Stapled haemorrhoidopexy: extent of tissue excision and clinical implications in the early postoperative period. Colorectal Dis . 2011 Jun. 13(6):697-702. [QxMD MEDLINE Link] .

Pattana-arun J, Wesarachawit W, Tantiphlachiva K, Atithansakul P, Sahakitrungruang C, Rojanasakul A. A comparison of early postoperative results between urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids and elective closed hemorrhoidectomy. J Med Assoc Thai . 2009 Dec. 92(12):1610-5. [QxMD MEDLINE Link] .

Bove A, Bongarzoni G, Palone G, Chiarini S, Calisesi EM, Corbellini L. Effective treatment of haemorrhoids: early complication and late results after 150 consecutive stapled haemorrhoidectomies. Ann Ital Chir . 2009 Jul-Aug. 80(4):299-303. [QxMD MEDLINE Link] .

Ratto C, Parello A, Veronese E, et al. Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial. Colorectal Dis . 2015 Jan. 17(1):O10-9. [QxMD MEDLINE Link] .

Bjelanovic Z, Draskovic M, Veljovic M, Lekovic I, Karanikolas M, Stamenkovic D. Transanal hemorrhoid dearterialization is a safe and effective outpatient procedure for the treatment of hemorrhoidal disease. Cir Esp . 2016 Dec. 94(10):588-94. [QxMD MEDLINE Link] .

Scheyer M, Antonietti E, Rollinger G, Lancee S, Pokorny H. Hemorrhoidal artery ligation (HAL) and rectoanal repair (RAR): retrospective analysis of 408 patients in a single center. Tech Coloproctol . 2015 Jan. 19(1):5-9. [QxMD MEDLINE Link] .

Perrotti P, Dominici P, Grossi E, Cerutti R, Antropoli C. Topical nifedipine with lidocaine ointment versus active control for pain after hemorrhoidectomy: results of a multicentre, prospective, randomized, double-blind study. Can J Surg . 2010 Feb. 53(1):17-24. [QxMD MEDLINE Link] . [Full Text] .

[Guideline] Russell MM, Ko CY. Management of hemorrhoids: mainstay of treatment remains diet modification and office-based procedures. National Guideline Clearinghouse. Available at https://guideline.gov/expert/expert-commentary.aspx?id=37828 . Accessed: October 11, 2014.

Elbetti C, Giani I, Novelli E, Fucini C, Martellucci J. The single pile classification: a new tool for the classification of haemorrhoidal disease and the comparison of treatment results. Updates Surg . 2015 Dec. 67(4):421-6. [QxMD MEDLINE Link] .

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• Hemorrhoids. Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.
• Hemorrhoids. Thrombosed hemorrhoid. This hemorrhoid was treated by incision and removal of a clot.

Contributor Information and Disclosures

Kyle R Perry, MD Emergency Physician, The Queen's Medical Center; Volunteer Faculty, University of Hawaii, John A Burns School of Medicine Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

William G Gossman, MD, FAAEM Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Chairman, Department of Emergency Medicine, Creighton University Medical Center William G Gossman, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine Disclosure: Nothing to disclose.

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association , American Physiological Society , American Society of Nephrology , Association for Academic Surgery , International Society of Nephrology , New York Academy of Sciences , Society for Surgery of the Alimentary Tract Disclosure: Nothing to disclose.

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma , Eastern Association for the Surgery of Trauma , Southern Surgical Association , American College of Chest Physicians , American College of Surgeons , American Medical Association , Association for Academic Surgery , Association for Surgical Education , Shock Society , Society of Critical Care Medicine , Southeastern Surgical Congress , Tennessee Medical Association Disclosure: Nothing to disclose.

Scott C Thornton, MD Associate Clinical Professor of Surgery, Yale University School of Medicine; Director, Colorectal Teaching, Bridgeport Hospital; Private Practice, Park Avenue Surgical Associates Scott C Thornton, MD is a member of the following medical societies: American Society of Colon and Rectal Surgeons Disclosure: Nothing to disclose.

Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine , American College of Emergency Physicians , Society for Academic Emergency Medicine Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors David R Gurley, MD, Richard Sinert, DO, and Pilar Guerrero, MD,to the development and writing of a source article.

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• Hemorrhoids
• Anal Surgery for Hemorrhoids
• Thrombosed External Hemorrhoid Excision
• Internal Hemorrhoid Band Ligation
• Hemorrhoidectomy, Hemorrhoidopexy, and Hemorrhoid Artery Ligation
• Rubber-Band Ligation of Hemorrhoids
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Case-based learning: haemorrhoids

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After reading this article, you should be able to:

• Recognise the symptoms of haemorrhoids and when referral is needed;
• Understand the pharmacological and non-pharmacological treatment options available, including any advice relating to self-care and prevention ;
• Know how to advise patients on the rectal application of creams/ointments and suppositories; 
• Understand that there are different presentations of haemorrhoids. 

Haemorrhoids are clusters of vascular tissue, smooth muscle and connective tissue arranged in three columns along the anal canal ​[1]​ . In healthy individuals, they act as cushions that help maintain continence ​[1]​ . Although haemorrhoids — or ‘piles’ as they are otherwise commonly known — are normal structures, the term has become synonymous with them in an abnormally swollen and symptomatic state ​[2]​ . This happens when the venous drainage of the anus is altered, causing the venous plexus (a congregation of multiple veins) and connecting tissue to dilate, creating an outgrowth from the rectal wall ​[3]​ .

The exact prevalence of haemorrhoids is unknown because many patients are asymptomatic and do not seek medical attention ​[3]​ . A US colorectal cancer screening study found a 39% prevalence of haemorrhoids, with 55% of those patients reporting no symptoms ​[3]​ . Community-based UK studies have reported that haemorrhoids affect 13–36% of the general population, although this estimate may be higher than the actual prevalence owing to self-reporting and the incorrect attribution of anorectal symptoms to haemorrhoids, such as pain and bleeding ​[1,2]​ .

NHS signposting for common clinical conditions and minor ailments encourages patients to seek prompt clinical advice and treatment from their local pharmacy. Therefore, acute or chronic presentations of haemorrhoids may frequently be seen in community pharmacies ​[4]​ and it is important that pharmacists can provide patients with the appropriate guidance and information for management.                                                  

Risk factors

The aetiology of haemorrhoids is currently speculative; however, this may change as large-scale studies are in progress to investigate the genetic causes ​[5]​ . Although unproven, a low-fibre diet and  constipation have historically been thought to be risk factors ​[1]​ . Other proposed risk factors include:

• Age — there is higher prevalence in persons aged 45–65 years; 
• Socioeconomic status — there is higher prevalence with higher socioeconomic status, although this may reflect differences in health-seeking behaviour rather than true prevalence; 
• Pregnancy ;
• Heavy lifting;
• Chronic cough ;
• Certain toilet behaviours, such as straining or spending more time on a seated toilet than on a squat toilet; squatting provides a better angle for defecation ​[1–7]​ .

Haemorrhoids are classified as external or internal depending on their position in relation to the dentate line (dividing the upper two-thirds from the lower third of the anal canal). External haemorrhoids originate below the dentate line and are covered by modified squamous epithelium, which is richly innervated with pain fibres ( see Figure 1 ). Internal haemorrhoids arise above the dentate line and are covered by columnar epithelium, which have no pain fibres. Internal haemorrhoids are graded by degree of prolapse using Goligher staging, although classification does not always reflect the severity of the symptoms ( see Figure 2 ) ​[8]​ . Internal and external haemorrhoids can be present at the same time ​[1,2]​ .

Signs and symptoms

External haemorrhoids are often described as lumps and bumps around the anus with itching. The latter is a result of irritation from faecal matter not being fully removed upon wiping ​[9]​ . Pain is uncommon unless very severely swollen owing to thrombosis ​[10]​ .

Symptoms of internal haemorrhoids will commonly include a feeling of discomfort and a sensation of fullness in the rectum or incomplete evacuation, especially after passing stools. Further straining should be avoided to prevent haemorrhoids from prolapsing ​[10]​ .   Prolapsed haemorrhoids may become itchy and irritated owing to the presence of moisture, mucus and faecal matter. Pain is not usually reported with internal haemorrhoids unless the haemorrhoid is prolapsed and strangulated; the latter occurring when the blood supply has been cut off by pressure applied from the anal muscles ​[2,10]​ .

Where bleeding is present, this will typically occur after bowel motions because of the microtrauma of passing hard stools. As this is arterial blood, it will usually be bright red in colour and may appear as streaks on toilet paper when wiping, on the surface of stools, or in the toilet water ​[2,10]​ . GP referral to exclude other diagnoses should be made if the blood has a different appearance, such as darker red, brown or black, or is mixed with the stool. These signs suggest a more proximal blood source and may be a ‘red flag’ cancer symptom ​[11,12]​ . Please see Box 1 for example questions that pharmacists can ask to assess symptoms. 

Box 1: Example questions that pharmacists may ask as part of symptom assessment

• “Can you describe to me your current symptoms and when you first noticed them?”
• “Do you feel the symptoms are getting worse, better or staying about the same?”
• “Have you had these sorts of symptoms before, or is this the first time you’ve felt like this?”
• “Aside from the discomfort around your back passage, how do you feel in general? Are you eating OK? Have you had any digestive problems recently, lost any weight or noticed any bleeding?” 
• “Have you already tried any medicines to help relieve these symptoms?” or “If you’ve felt like this before were there any treatments you tried previously that helped?” 

Pharmacists have a duty of care to refer patients who present with ‘red flag’ symptoms, but where the bleeding is mild and localised, and in the absence of other red flags ( see Figure 3 ​[2,12–14]​ ), treatment initiation with appropriate safety-netting advice and follow up guidance may be appropriate ​[12]​ .

Thorough history taking will help the pharmacist to exclude other potential causes or alternative diagnoses. See Box 2 for a list of differential diagnoses.

Box 2: Differential diagnoses

Differential diagnoses of haemorrhoids include:

• Adenomatous polyps;
• Anal fissure;
• Anal or colorectal cancer ;
• Anorectal fistula;
• Condylomata acuminata (warts);
• Diverticular disease ;
• Inflammatory bowel disease ;
• Perianal abscess;
• Portal hypertension;
• Pruritus ani and associated causes;
• Rectal prolapse;
• Sexually transmitted infections (e.g. gonorrhoea , syphilis or chancroid) ​[2]​ .

Complications

Pharmacists should advise surveillance of the affected area in case dermatological complications develop. The skin may become macerated owing to mucus discharge, ulcerated owing to thrombosed external haemorrhoids, or irritated, secondary to skin tags ​[2]​ . Changes that suggest signs of infection or of skin breakdown should be referred for review. 

A drop in haemogloblin may be detected when there is significant or continuous rectal bleeding. Signs and symptoms of anaemia may include fatigue, breathlessness or pale skin. Pharmacists should refer this to be managed by the GP who will confirm the diagnosis using a blood test ​[2,15]​ .  

For some complications, such as incarcerated or thrombosed haemorrhoids, surgical intervention may be indicated to resolve symptoms and promote quicker healing. Referral for surgical correction or dilation may also be indicated where a narrowing of the anal canal, also known as anal stenosis, has developed over time ​[2,8]​ .

In more serious cases where infection has developed in the area, there is the risk of pelvic  sepsis . All cases of suspected sepsis need urgent hospital referral to ensure first doses of antibiotics are administered in-line with antimicrobial policies ​[2,16]​ . 

Complications of haemorrhoids can negatively affect quality of life and so appropriate signposting and advice should be given when making recommendations to ensure timely and appropriate escalation of management.

Treatment and management

In the absence of complications, haemorrhoids are self-limiting and typically heal within a week ​[7]​ . Where they are associated with pain, itching or discomfort, pharmacists may offer pharmacological treatment to promote healing and to alleviate symptoms ​[6]​ . Pharmacists should be prepared to offer lifestyle advice to aid healing and prevent recurrence. 

Pharmacological management

The treatment of haemorrhoids in the community and primary care setting is usually limited to topical preparations that contain combinations of astringents, local anaesthetics and corticosteroids ​[10]​ . There is currently no evidence to suggest any one topical preparation is more effective than another. Simple analgesia may also be recommended for pain relief, although non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided in the presence of rectal bleeding ​[6,7,17]​ .

Pharmacists should recommend onward referral to a GP if self-treatment with a non-prescription product does not improve symptoms within the first seven days of use. This is the typical treatment duration guidance issued in the product licenses for over-the-counter preparations ​[6]​ . Advice to avoid prolonged use of topical preparations also reflects the potential for ingredients to cause problematic effects if used over extended periods. For example, prolonged use of topical corticosteroids may cause skin atrophy, sensitisation and contact dermatitis, while extended use of topical local anaesthetics is associated with skin sensitisation ​[6,17]​ .   Side effects are rare and usually limited to minor irritations for short courses of treatment.

Creams and ointments are usually the products of choice for external haemorrhoids and are typically applied morning and evening. They can also be applied after passing stools when symptoms often flare, using a clean finger or gauze dressing.

Suppositories are usually the best choice for internal haemorrhoids, although some topical preparations come packaged with an applicator that will apply the product into the anal passage. Suppositories can be inserted morning and evening and after passing stools. Pharmacy staff should counsel on the best ways to insert suppositories ​[18]​ . Practical advice on the insertion of rectal formulations is available in Box 1 of this article .

For patients with external and internal haemorrhoids, a suppository and topical product can be used at the same time. Information regarding counselling on suppository use can be found  here .

Self-care and prevention

Self-care recommendations should be made to support the relief of symptoms and the healing process. This may include the use of a cold compresses to shrink the haemorrhoids, warm baths to soothe the area and the promotion of certain behaviours ​[2,7,17,19]​ . Adoption of the following behaviours may promote healing and help to prevent repeated episodes:

• A balanced diet with enough fibre (25-30g daily via high fibre foods or commercial supplements);
• Adequate fluid intake;
• Regular physical activity;
• Maintain stools that are soft and easy to pass;
• Avoid constipation and straining;
• Toilet behaviours, such as going as soon as you need and avoiding sitting on the toilet for long periods;
• Anal hygiene, such as moist, gentle cleaning following a bowel movement;
• Keeping a healthy weight ​[2,7,17,19]​ . 

If dispensing or recommending a medication that can cause constipation, pharmacists should be prepared to give appropriate counselling advice that encourages a normal bowel frequency to be maintained ​[6]​ . This should be a frequency that is ‘normal’ for the patient.

Minimally invasive and surgical management 

Referral to secondary care for consideration of further management may be indicated depending on the severity of symptoms and degree of prolapse. This will usually be for haemorrhoids that have failed to respond to or have recurred despite conservative management, are graded II–IV, or where the haemorrhoid is incarcerated or thrombosed ​[20–22]​ .

Incarcerated haemorrhoids are short-term complications that present as severe pain and irreducible prolapsing haemorrhoidal tissue. A referral for surgical intervention is indicated to manage these ​[19,20]​ .

Surgical intervention may also be indicated for patients who present early with severe symptoms of thrombosis, as this may lead to a quicker resolution of symptoms ​[22]​ . However, most patients with thrombosed haemorrhoids can be managed conservatively at home using analgesia, ice packs and stool softeners, with a topical calcium antagonist if required as an adjunct for pain relief. These should be given in combination with advice to avoid straining and constipation ​[8]​ .

Most minimally invasive (i.e. non-surgical) or surgical procedures will be performed as day cases ​[7]​ .

Case 1: Pregnancy

A 30-year-old woman presents at her pharmacy seeking advice on managing suspected piles. She explains to the assistant that she is six months’ pregnant and is referred to the pharmacist in the consultation room. 

Consultation

The patient explains that she has noticed a small lump around her back passage and has seen some bright red streaks of blood on toilet paper when wiping after defecation. It is quite tender but not painful. She describes no change in bowel habit but may be straining slightly when passing stools.

Diagnosis and advice

The pharmacist highlights that the symptoms are typical of haemorrhoids and a non-prescription treatment can be recommended. A simple, soothing product containing astringents in ointment form would be a safe, suitable option ​[17]​ . The patient is given a leaflet from the UK Teratology Information Service’s ‘bumps’ website for additional reassurance regarding the safe treatment of haemorrhoids and its common occurrence in pregnancy ​[23]​ . She is advised to see her GP if her symptoms worsen or do not resolve in the next few days.

The patient is also given dietary and lifestyle advice to prevent constipation and straining, as these can worsen haemorrhoids or cause them to recur. 

Case 2: Patient seeking medication advice

A 65-year-old man makes a request at the pharmacy to switch his prescription for cinchocaine hydrochloride 0.5% ww with hydrocortisone 0.5% ww suppositories to ointment. 

To avoid the consultation being overheard, the pharmacist takes the patient into the consultation room. The patient explains that his GP has examined him and suggested suppositories would be more effective for him owing to their position. He reveals he is reluctant to leave the pharmacy with the suppositories as he does not know how to use them. The pharmacist explains that both formulations contain the same ingredients, which relieve pain, itching and reduce inflammation, and explains how to use the prescribed medication. 

When the pharmacist checks the patient’s understanding using the teach-back method, the patient confides that he does not think that he will be able to do this at work ​[24]​ . The pharmacist reassures the patient and provides advice on application standing up. As the pharmacist is a community pharmacist independent prescriber, the patient is encouraged to return if he has difficulties, when they could discuss the supply of a prescription-only ointment for use at work. The patient is given patient information leaflets to help prevent a further recurrence ​[7,18]​ .

Case 3: Haemorrhoid complication

A 45-year-old woman presents to the pharmacy at the weekend asking for haemorrhoid treatment. She is distressed when describing a swelling around her back passage which is “extremely tender and painful”.

The pharmacist takes a patient history, which includes a recent knee injury managed with PRICE (protection, rest, ice, compression, elevation) therapy, a two-week sick note for her employer and prescriptions for co-codamol. 

The patient has no prior issues with her bowels, but over the past week has been straining when going to the toilet and passing stools less frequently than normal. The painful swelling at her back passage started two days ago and, after looking up the symptoms online, she has been using cold compresses on the area. She is now avoiding going to the toilet.

Based on the patient consultation, the pharmacist suspects a thrombosed external haemorrhoid.

The pharmacist highlights the risk factors for haemorrhoids and the contributory roles of opioids and immobility in inducing constipation. The pharmacist explains that thrombosed haemorrhoids can be managed conservatively or with surgical intervention, the latter providing quicker resolution of symptoms. Owing to the patient’s acute presentation, the pharmacist advises the patient to go to a hospital emergency department for further assessment. 

• 1 Sandler RS, Peery AF. Rethinking What We Know About Hemorrhoids. Clinical Gastroenterology and Hepatology. 2019; 17 :8–15. doi: 10.1016/j.cgh.2018.03.020
• 2 NICE Clinical Knowledge Summary. Haemorrhoids. National Institute for Health and Care Excellence. 2016. https://cks.nice.org.uk/topics/haemorrhoids (accessed Jan 2022).
• 3 Mott T, Latimer K, Edwards C. Hemorrhoids: Diagnosis and Treatment Options. Am Fam Physician 2018; 97 :172–9. https://www.ncbi.nlm.nih.gov/pubmed/29431977
• 4 How your pharmacy can help. NHS. https://www.nhs.uk/nhs-services/prescriptions-and-pharmacies/pharmacies/how-your-pharmacy-can-help/ (accessed Jan 2022).
• 5 Zheng T, Ellinghaus D, Juzenas S, et al. Genome-wide analysis of 944 133 individuals provides insights into the etiology of haemorrhoidal disease. Gut. 2021; 70 :1538–49. doi: 10.1136/gutjnl-2020-323868
• 6 Haemorrhoids (piles). NHS Inform. 2021. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/haemorrhoids-piles (accessed Jan 2022).
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• 23 Bumps. Best use of medicines in pregnancy. UK teratology information service. https://www.medicinesinpregnancy.org/#:~:text=Bump%20leaflets%20are%20produced%20by%20the%20UK%20Teratology,England%20on%20behalf%20of%20the%20UK%20Health%20Departments (accessed Jan 2022).
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Anatomy, Physiology, and Pathophysiology of Hemorrhoids

• Living reference work entry
• First Online: 09 May 2017
• Cite this living reference work entry

• Varut Lohsiriwat 5  

Part of the book series: Coloproctology ((COLOPROCT))

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The understanding of anatomy, physiology, and pathophysiology of hemorrhoids is fundamental to selecting an appropriate treatment of hemorrhoids, improving treatment outcomes, developing novel methods for managing hemorrhoids, and preventing recurrent diseases. This chapter deals with some essential knowledge and current views of applied anatomy, anorectal physiology, and pathophysiology of hemorrhoids – which includes four main concepts of hemorrhoid formation: sliding anal cushions (loss of fixation network), vascular abnormality (dysregulation of vascular tone, high arterial blood flow, venous hypertension of anorectal vascular plexus, vascular hyperplasia, and neovascularization), rectal redundancy, and an increased pressure on anorectal vascular plexus.

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Lohsiriwat, V. (2017). Anatomy, Physiology, and Pathophysiology of Hemorrhoids. In: Ratto, C., Parello, A., Litta, F. (eds) Hemorrhoids. Coloproctology. Springer, Cham. https://doi.org/10.1007/978-3-319-51989-0_2-1

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Hemorrhoids: From basic pathophysiology to clinical management

Correspondence to: Varut Lohsiriwat, MD, PhD, Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Prannok Road, Bangkok 10700, Thailand. moc.liamtoh@noollob

Telephone: +66-0-24198077 Fax: +66-0-24115009

This review discusses the pathophysiology, epidemiology, risk factors, classification, clinical evaluation, and current non-operative and operative treatment of hemorrhoids. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoids. It appears that the dysregulation of the vascular tone and vascular hyperplasia might play an important role in hemorrhoidal development, and could be a potential target for medical treatment. In most instances, hemorrhoids are treated conservatively, using many methods such as lifestyle modification, fiber supplement, suppository-delivered anti-inflammatory drugs, and administration of venotonic drugs. Non-operative approaches include sclerotherapy and, preferably, rubber band ligation. An operation is indicated when non-operative approaches have failed or complications have occurred. Several surgical approaches for treating hemorrhoids have been introduced including hemorrhoidectomy and stapled hemorrhoidopexy, but postoperative pain is invariable. Some of the surgical treatments potentially cause appreciable morbidity such as anal stricture and incontinence. The applications and outcomes of each treatment are thoroughly discussed.

INTRODUCTION

Hemorrhoids are a very common anorectal condition defined as the symptomatic enlargement and distal displacement of the normal anal cushions. They affect millions of people around the world, and represent a major medical and socioeconomic problem. Multiple factors have been claimed to be the etiologies of hemorrhoidal development, including constipation and prolonged straining. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoidal disease[ 1 ]. An inflammatory reaction[ 2 ] and vascular hyperplasia[ 3 , 4 ] may be evident in hemorrhoids. This article firstly reviewed the pathophysiology and other clinical backgrounds of hemorrhoidal disease, followed by the current approaches to non-operative and operative management.

PATHOPHYSIOLOGY OF HEMORRHOIDAL DISEASE

The exact pathophysiology of hemorrhoidal development is poorly understood. For years the theory of varicose veins, which postulated that hemorrhoids were caused by varicose veins in the anal canal, had been popular but now it is obsolete because hemorrhoids and anorectal varices are proven to be distinct entities. In fact, patients with portal hypertension and varices do not have an increased incidence of hemorrhoids[ 5 ].

Today, the theory of sliding anal canal lining is widely accepted[ 6 ]. This proposes that hemorrhoids develop when the supporting tissues of the anal cushions disintegrate or deteriorate. Hemorrhoids are therefore the pathological term to describe the abnormal downward displacement of the anal cushions causing venous dilatation. There are typically three major anal cushions, located in the right anterior, right posterior and left lateral aspect of the anal canal, and various numbers of minor cushions lying between them[ 7 ] (Figure ​ (Figure1). 1 ). The anal cushions of patients with hemorrhoids show significant pathological changes. These changes include abnormal venous dilatation, vascular thrombosis, degenerative process in the collagen fibers and fibroelastic tissues, distortion and rupture of the anal subepithelial muscle (Figure ​ (Figure2). 2 ). In addition to the above findings, a severe inflammatory reaction involving the vascular wall and surrounding connective tissue has been demonstrated in hemorrhoidal specimens, with associated mucosal ulceration, ischemia and thrombosis[ 2 ].

Diagram of common sites of major anal and internal hemorrhoids. A: Diagram of common sites of major anal cushions; B: Common sites of internal hemorrhoids.

Pathological changes in hemorrhoids. *: Marked dilatation of hemorrhoidal venous plexus; #: Fragmented anal subepithelial muscle (the Treitz’s muscle or mucosal suspensory ligament) (Scale bar = 1 mm).

Several enzymes or mediators involving the degradation of supporting tissues in the anal cushions have been studied. Among these, matrix metalloproteinase (MMP), a zinc-dependent proteinase, is one of the most potent enzymes, being capable of degrading extracellular proteins such as elastin, fibronectin, and collagen. MMP-9 was found to be over-expressed in hemorrhoids, in association with the breakdown of elastic fibers[ 8 ]. Activation of MMP-2 and MMP-9 by thrombin, plasmin or other proteinases resulted in the disruption of the capillary bed and promotion of angioproliferative activity of transforming growth factor β (TGF-β)[ 9 ].

Recently, increased microvascular density was found in hemorrhoidal tissue, suggesting that neovascularization might be another important phenomenon of hemorrhoidal disease. In 2004, Chung et al[ 4 ] reported that endoglin (CD105), which is one of the binding sites of TGF-β and is a proliferative marker for neovascularization, was expressed in more than half of hemorrhoidal tissue specimens compared to none taken from the normal anorectal mucosa. This marker was prominently found in venules larger than 100 μm. Moreover, these workers found that microvascular density increased in hemorrhoidal tissue especially when thrombosis and stromal vascular endothelial growth factors (VEGF) were present. Han et al[ 8 ] also demonstrated that there was a higher expression of angiogenesis-related protein such as VEGF in hemorrhoids.

Regarding the study of morphology and hemodynamics of the anal cushions and hemorrhoids, Aigner et al[ 3 , 10 ] found that the terminal branches of the superior rectal artery supplying the anal cushion in patients with hemorrhoids had a significantly larger diameter, greater blood flow, higher peak velocity and acceleration velocity, compared to those of healthy volunteers. Moreover, an increase in arterial caliber and flow was well correlated with the grades of hemorrhoids. These abnormal findings still remained after surgical removal of the hemorrhoids, confirming the association between hypervascularization and the development of hemorrhoids.

Using an immunohistochemical approach, Aigner et al[ 3 ] also identified a sphincter-like structure, formed by a thickened tunica media containing 5-15 layers of smooth muscle cells, between the vascular plexus within the subepithelial space of the anal transitional zone in normal anorectal specimens. Unlike the normal specimens, hemorrhoids contained remarkably dilated, thin-walled vessels within the submucosal arteriovenous plexus, with absent or nearly-flat sphincter-like constriction on the vessels. These investigators concluded that a smooth muscle sphincter in the arteriovenous plexus helps in reducing the arterial inflow, thus facilitating an effective venous drainage. Aigner et al[ 3 ] then proposed that, if this mechanism is impaired, hyperperfusion of the arteriovenous plexus will lead to the formation of hemorrhoids.

Based on the histological findings of abnormal venous dilatation and distortion in hemorrhoids, dysregulation of the vascular tone might play a role in hemorrhoidal development. Basically, vascular smooth muscle is regulated by the autonomic nervous system, hormones, cytokines and overlying endothelium. Imbalance between endothelium-derived relaxing factors (such as nitric oxide, prostacyclin, and endothelium-derived hyperpolarizing factor) and endothelium-derived vasoconstricting factors (such as reactive oxygen radicals and endothelin) causes several vascular disorders[ 11 ]. In hemorrhoids, nitric oxide synthase, an enzyme which synthesizes nitric oxide from L-arginine, was reported to increase significantly[ 8 ].

Several physiological changes in the anal canal of patients with hemorrhoids have been observed. Sun et al[ 12 ] revealed that resting anal pressure in patients with non-prolapsing or prolapsing hemorrhoids was much higher than in normal subjects, whereas there was no significant change in the internal sphincter thickness. Ho et al[ 13 ] performed anorectal physiological studies in 24 patients with prolapsed hemorrhoids and compared with results in 13 sex- and age-matched normal subjects. Before operation, those with hemorrhoids had significantly higher resting anal pressures, lower rectal compliance, and more perineal descent. The abnormalities found reverted to the normal range within 3 mo after hemorrhoidectomy, suggesting that these physiological changes are more likely to be an effect, rather than the cause, of hemorrhoidal disease.

EPIDEMIOLOGY AND RISK FACTORS OF HEMORRHOIDS

Although hemorrhoids are recognized as a very common cause of rectal bleeding and anal discomfort, the true epidemiology of this disease is unknown because patients have a tendency to use self-medication rather than to seek proper medical attention. An epidemiologic study by Johanson et al[ 14 ] in 1990 showed that 10 million people in the United States complained of hemorrhoids, corresponding to a prevalence rate of 4.4%. In both sexes, peak prevalence occurred between age 45-65 years and the development of hemorrhoids before the age of 20 years was unusual. Whites and higher socioeconomic status individuals were affected more frequently than blacks and those of lower socioeconomic status. However, this association may reflect differences in health-seeking behavior rather than true prevalence. In the United Kingdom, hemorrhoids were reported to affect 13%-36% of the general population[ 1 , 15 ]. However, this estimation may be higher than actual prevalence because the community-based studies mainly relied on self-reporting and patients may attribute any anorectal symptoms to hemorrhoids.

Constipation and prolonged straining are widely believed to cause hemorrhoids because hard stool and increased intraabdominal pressure could cause obstruction of venous return, resulting in engorgement of the hemorrhoidal plexus[ 1 ]. Defecation of hard fecal material increases shearing force on the anal cushions. However, recent evidence questions the importance of constipation in the development of this common disorder[ 14 , 16 , 17 ]. Many investigators have failed to demonstrate any significant association between hemorrhoids and constipation, whereas some reports suggested that diarrhea is a risk factor for the development of hemorrhoids[ 16 ]. Increase in straining for defecation may precipitate the development of symptoms such as bleeding and prolapse in patients with a history of hemorrhoidal disease. Pregnancy can predispose to congestion of the anal cushion and symptomatic hemorrhoids, which will resolve spontaneously soon after birth. Many dietary factors including low fiber diet, spicy foods and alcohol intake have been implicated, but reported data are inconsistent[ 1 ].

CLASSIFICATION AND GRADING OF HEMORRHOIDS

A hemorrhoid classification system is useful not only to help in choosing between treatments, but also to allow the comparison of therapeutic outcomes among them. Hemorrhoids are generally classified on the basis of their location and degree of prolapse. Internal hemorrhoids originate from the inferior hemorrhoidal venous plexus above the dentate line and are covered by mucosa, while external hemorrhoids are dilated venules of this plexus located below the dentate line and are covered with squamous epithelium. Mixed (interno-external) hemorrhoids arise both above and below the dentate line. For practical purposes, internal hemorrhoids are further graded based on their appearance and degree of prolapse, known as Goligher’s classification: (1) First-degree hemorrhoids (grade I): The anal cushions bleed but do not prolapse; (2) Second-degree hemorrhoids (grade II): The anal cushions prolapse through the anus on straining but reduce spontaneously; (3) Third-degree hemorrhoids (grade III): The anal cushions prolapse through the anus on straining or exertion and require manual replacement into the anal canal; and (4) Fourth-degree hemorrhoids (grade IV): The prolapse stays out at all times and is irreducible. Acutely thrombosed, incarcerated internal hemorrhoids and incarcerated, thrombosed hemorrhoids involving circumferential rectal mucosal prolapse are also fourth-degree hemorrhoids[ 18 ].

Some authors proposed classifications based on anatomical findings of hemorrhoidal position, described as primary (at the typical three sites of the anal cushions), secondary (between the anal cushions), or circumferential, and based on symptoms described as prolapsing and non-prolapsing[ 19 ]. However, these classifications are in less widespread use.

CLINICAL EVALUATION OF HEMORRHOIDS

The most common manifestation of hemorrhoids is painless rectal bleeding associated with bowel movement, described by patients as blood drips into toilet bowl. The blood is typically bright red as hemorrhoidal tissue has direct arteriovenous communication[ 3 ]. Positive fecal occult blood or anemia should not be attributed to hemorrhoids until the colon is adequately evaluated especially when the bleeding is atypical for hemorrhoids, when no source of bleeding is evident on anorectal examination, or when the patient has significant risk factors for colorectal neoplasia[ 18 ].

Prolapsing hemorrhoids may cause perineal irritation or anal itching due to mucous secretion or fecal soiling. A feeling of incomplete evacuation or rectal fullness is also reported in patients with large hemorrhoids. Pain is not usually caused by the hemorrhoids themselves unless thrombosis has occurred, particularly in an external hemorrhoid or if a fourth-degree internal hemorrhoid becomes strangulated. Anal fissure and perianal abscess are more common causes of anal pain in hemorrhoidal patients.

The definite diagnosis of hemorrhoidal disease is based on a precise patient history and careful clinical examination. Assessment should include a digital examination and anoscopy in the left lateral position. The perianal area should be inspected for anal skin tags, external hemorrhoid, perianal dermatitis from anal discharge or fecal soiling, fistula-in-ano and anal fissure. Some physicians prefer patients sitting and straining in the squatting position to watch for the prolapse. Although internal hemorrhoids cannot be palpated, digital examination will detect abnormal anorectal mass, anal stenosis and scar, evaluate anal sphincter tone, and determine the status of prostatic hypertrophy which may be the reason for straining as this aggravates descent of the anal cushions during micturition. Hemorrhoidal size, location, severity of inflammation and bleeding should be noted during anoscopy. Intrarectal retroflexion of the colonoscope or transparent anoscope with flexible endoscope also allow excellent visualization of the anal canal and hemorrhoid, and permit recording pictures[ 20 ].

MANAGEMENT OF HEMORRHOIDAL DISEASE

Therapeutic treatment of hemorrhoids ranges from die-tary and lifestyle modification to radical surgery, depending on degree and severity of symptoms[ 21 , 22 ]. The current management of internal hemorrhoids is illustrated in Table ​ Table1. 1 . In addition, selected meta-analyses showing various treatment options of hemorrhoidal disease are shown in Table ​ Table2 2 [ 23 - 32 ].

Current management of internal hemorrhoids by grade

DGHAL: Doppler-guided hemorrhoidal artery ligation; ×: Applicable.

Selected meta-analyses showing various treatment options for hemorrhoidal disease (in order of publication year)

Dietary and lifestyle modification

Since shearing action of passing hard stool on the anal mucosa may cause damage to the anal cushions and lead to symptomatic hemorrhoids, increasing intake of fiber or providing added bulk in the diet might help eliminate straining during defecation. In clinical studies of hemorrhoids, fiber supplement reduced the risk of persisting symptoms and bleeding by approximately 50%, but did not improve the symptoms of prolapse, pain, and itching[ 26 ]. Fiber supplement is therefore regarded as an effective treatment in non-prolapsing hemorrhoids; however, it could take up to 6 wk for a significant improvement to be manifest[ 33 ]. As fiber supplements are safe and cheap, they remain an integral part of both initial treatment and of a regimen following other therapeutic modalities of hemorrhoids.

Lifestyle modification should also be advised to any patients with any degree of hemorrhoids as a part of treatment and as a preventive measure. These changes include increasing the intake of dietary fiber and oral fluids, reducing consumption of fat, having regular exercise, improving anal hygiene, abstaining from both straining and reading on the toilet, and avoiding medication that causes constipation or diarrhea.

Medical treatment

Oral flavonoids : These venotonic agents were first described in the treatment of chronic venous insufficiency and edema. They appeared to be capable of increasing vascular tone, reducing venous capacity, decreasing capillary permeability[ 34 ], and facilitating lymphatic drainage[ 35 ] as well as having anti-inflammatory effects[ 36 ]. Although their precise mechanism of action remains unclear, they are used as an oral medication for hemorrhoidal treatment, particularly in Europe and Asia. Micronized purified flavonoid fraction (MPFF), consisting of 90% diosmin and 10% hesperidin, is the most common flavonoid used in clinical treatment[ 27 ]. The micronization of the drug to particles of less than 2 μm not only improved its solubility and absorption, but also shortened the onset of action. A recent meta-analysis of flavonoids for hemorrhoidal treatment, including 14 randomized trials and 1514 patients, suggested that flavonoids decreased risk of bleeding by 67%, persistent pain by 65% and itching by 35%, and also reduced the recurrence rate by 47%[ 27 ]. Some investigators reported that MPFF can reduce rectal discomfort, pain and secondary hemorrhage following hemorrhoidectomy[ 37 ].

Oral calcium dobesilate : This is another venotonic drug commonly used in diabetic retinopathy and chronic venous insufficiency as well as in the treatment of acute symptoms of hemorrhoids[ 38 ]. It was demonstrated that calcium dobesilate decreased capillary permeability, inhibited platelet aggregation and improved blood viscosity; thus resulting in reduction of tissue edema[ 39 ]. A clinical trial of hemorrhoid treatment showed that calcium dobesilate, in conjunction with fiber supplement, provided an effective symptomatic relief from acute bleeding, and it was associated with a significant improvement in the inflammation of hemorrhoids[ 40 ].

Topical treatment: The primary objective of most topical treatment aims to control the symptoms rather than to cure the disease. Thus, other therapeutic treatments could be subsequently required. A number of topical preparations are available including creams and suppositories, and most of them can be bought without a prescription. Strong evidence supporting the true efficacy of these drugs is lacking. These topical medications can contain various ingredients such as local anesthesia, corticosteroids, antibiotics and anti-inflammatory drugs[ 41 ].

Topical treatment may be effective in selected groups of hemorrhoidal patients. For instance, Tjandra et al[ 42 ] showed a good result with topical glyceryl trinitrate 0.2% ointment for relieving hemorrhoidal symptoms in patients with low-grade hemorrhoids and high resting anal canal pressures. However, 43% of the patients experienced headache during the treatment. Perrotti et al[ 43 ] reported the good efficacy of local application of nifedipine ointment in treatment of acute thrombosed external hemorrhoids. It is worth noting that the effect of topical application of nitrite and calcium channel blocker on the symptomatic relief of hemorrhoids may be a consequence of their relaxation effect on the internal anal sphincter, rather than on the hemorrhoid tissue per se where one might anticipate a predominantly vasodilator effect.

Apart from topical medication influencing tone of the internal anal sphincter, some topical treatment targets vasoconstriction of the vascular channels within hemorrhoids such as Preparation-H ® (Pfizer, United States), which contains 0.25% phenylephrine, petrolatum, light mineral oil, and shark liver oil. Phenylephrine is a vasoconstrictor having preferential vasopressor effect on the arterial site of circulation, whereas the other ingredients are considered protectants. Preparation-H is available in many forms, including ointment, cream, gel, suppositories, and medicated and portable wipes[ 44 ]. It provides temporary relief of acute symptoms of hemorrhoids, such as bleeding and pain on defecation.

Non-operative treatment

Sclerotherapy: This is currently recommended as a treatment option for first- and second-degree hemorrhoids. The rationale of injecting chemical agents is to create a fixation of mucosa to the underlying muscle by fibrosis. The solutions used are 5% phenol in oil, vegetable oil, quinine, and urea hydrochloride or hypertonic salt solution[ 22 ]. It is important that the injection be made into submucosa at the base of the hemorrhoidal tissue and not into the hemorrhoids themselves; otherwise, it can cause immediate transient precordial and upper abdominal pain[ 45 ]. Misplacement of the injection may also result in mucosal ulceration or necrosis, and rare septic complications such as prostatic abscess and retroperitoneal sepsis[ 46 ]. Antibiotic prophylaxis is indicated for patients with predisposing valvular heart disease or immunodeficiency because of the possibility of bacteremia after sclerotherapy[ 47 ].

Rubber band ligation: Rubber band ligation (RBL) is a simple, quick, and effective means of treating first- and second-degree hemorrhoids and selected patients with third-degree hemorrhoids. Ligation of the hemorrhoidal tissue with a rubber band causes ischemic necrosis and scarring, leading to fixation of the connective tissue to the rectal wall. Placement of rubber band too close to the dentate line may cause severe pain due to the presence of somatic nerve afferents and requires immediate removal. RBL is safely performed in one or more than one place in a single session[ 48 ] with one of several commercially available instruments, including hemorrhoid ligator rectoscope[ 49 ] and endoscopic ligator[ 50 ] which use suction to draw the redundant tissue in to the applicator to make the procedure a one-person effort.

The most common complication of RBL is pain or rectal discomfort, which is usually relieved by warm sitz baths, mild analgesics and avoidance of hard stool by taking mild laxatives or bulk-forming agents. Other complications include minor bleeding from mucosal ulceration, urinary retention, thrombosed external hemorrhoids, and extremely rarely, pelvic sepsis. The patients should stop taking anticoagulants for one week before and two weeks after RBL.

Infrared coagulation: The infrared coagulator produces infrared radiation which coagulates tissue and evaporizes water in the cell, causing shrinkage of the hemorrhoid mass. A probe is applied to the base of the hemorrhoid through the anoscope and the recommended contact time is between 1.0-1.5 s, depending on the intensity and wavelength of the coagulator[ 51 ]. The necrotic tissue is seen as a white spot after the procedure and eventually heals with fibrosis. Compared with sclerotherapy, infrared coagulation (IRC) is less technique-dependent and avoids the potential complications of misplaced sclerosing injection[ 22 ]. Although IRC is a safe and rapid procedure, it may not be suitable for large, prolapsing hemorrhoids.

Radiofrequency ablation: Radiofrequency ablation (RFA) is a relatively new modality of hemorrhoidal treatment. A ball electrode connected to a radiofrequency generator is placed on the hemorrhoidal tissue and causes the contacting tissue to be coagulated and evaporized[ 52 ]. By this method, vascular components of hemorrhoids are reduced and hemorrhoidal mass will be fixed to the underlying tissue by subsequent fibrosis. RFA can be performed on an outpatient basis and via an anoscope similar to sclerotherapy. Its complications include acute urinary retention, wound infection, and perianal thrombosis. Although RFA is a virtually painless procedure, it is associated with a higher rate of recurrent bleeding and prolapse[ 53 ].

Cryotherapy: Cryotherapy ablates the hemorrhoidal tissue with a freezing cryoprobe. It has been claimed to cause less pain because sensory nerve endings are destroyed at very low temperature. However, several clinical trials revealed that it was associated with prolonged pain, foul-smelling discharge and a high rate of persistent hemorrhoidal mass[ 54 ]. It is therefore rarely used.

There are two meta-analyses comparing outcomes among the three common non-operative treatments of hemorrhoids (sclerotherapy, RBL and IRC)[ 23 , 24 ]. These two studies demonstrated that RBL resulted in the fewest recurrent symptoms of hemorrhoids and the lowest rate of retreatment, but that it led to a significantly higher incidence of pain following the procedure. Hence, RBL could be recommended as the initial non-operative modality for treatment of grade I-III hemorrhoids. In a British survey of almost 900 general and colorectal surgeons[ 55 ], RBL was the most common procedure performed, following by sclerotherapy and hemorrhoidectomy.

Operative treatment

An operation is indicated when non-operative approaches have failed or complications have occurred. Different philosophies regarding the pathogenesis of hemorrhoidal disease creates different surgical approaches (Table ​ (Table3 3 ).

Summary of different philosophies regarding the pathogenesis of hemorrhoids and related surgical approaches

Hemorrhoidectomy: Excisional hemorrhoidectomy is the most effective treatment for hemorrhoids with the lowest rate of recurrence compared to other modalities[ 24 ]. It can be performed using scissors, diathermy[ 56 , 57 ], or vascular-sealing device such as Ligasure (Covidien, United States)[ 29 , 58 ] and Harmonic scalpel (Ethicon Endosurgery, United States)[ 59 , 60 ]. Excisional hemorrhoidectomy can be performed safely under perianal anesthetic infiltration as an ambulatory surgery[ 61 , 62 ]. Indications for hemorrhoidectomy include failure of non-operative management, acute complicated hemorrhoids such as strangulation or thrombosis, patient preference, and concomitant anorectal conditions such as anal fissure or fistula-in-ano which require surgery[ 18 ]. In clinical practice, the third-degree or fourth-degree internal hemorrhoids are the main indication for hemorrhoidectomy.

A major drawback of hemorrhoidectomy is postoperative pain[ 62 ]. There has been evidence that Ligasure hemorrhoidectomy results in less postoperative pain, shorter hospitalization, faster wound healing and convalescence compared to scissors or diathermy hemorrhoidectomy[ 63 - 65 ]. Other postoperative complications include acute urinary retention (2%-36%), postoperative bleeding (0.03%-6%), bacteremia and septic complications (0.5%-5.5%), wound breakdown, unhealed wound, loss of anal sensation, mucosa prolapse, anal stricture (0%-6%), and even fecal incontinence (2%-12%)[ 66 - 69 ]. Recent evidence has suggested that hemorrhoidal specimens can be exempt from pathological examination if no malignancy is suspected[ 70 ].

Plication: Plication is capable of restoring anal cushions to their normal position without excision. This procedure involves oversewing of hemorrhoidal mass and tying a knot at the uppermost vascular pedicle. However, there are still a number of potential complications following this procedure such as bleeding and pelvic pain[ 21 ].

Doppler-guided hemorrhoidal artery ligation: A new technique based on doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery was introduced in 1995 as an alternative to hemorrhoidectomy[ 71 ]. Doppler-guided hemorrhoidal artery ligation (DGHAL) has become increasingly popular in Europe. The rationale of this treatment was later supported by the findings from vascular studies[ 3 , 10 ], which demonstrated that patients with hemorrhoids had increased caliber and arterial blood flow of the terminal branch of the superior rectal arteries. Therefore, ligating the arterial supply to hemorrhoidal tissue by suture ligation may improve hemorrhoidal symptoms. DGHAL is most effective for second- or third-degree hemorrhoids. Notably, DGHAL may not improve prolapsing symptoms in advanced hemorrhoids. Short-term outcomes and 1-year recurrence rates of DGHAL did not differ from those of conventional hemorrhoidectomy[ 72 ]. Given the fact that there is the possibility of revascularization and recurrence of symptomatic hemorrhoids, further studies on the long-term outcomes of DGHAL are still required[ 73 ].

Stapled hemorrhoidopexy: Stapled hemorrhoidopexy (SH) has been introduced since 1998[ 74 ]. A circular stapling device is used to excise a ring of redundant rectal mucosa proximal to hemorrhoids and resuspend the hemorrhoids back within the anal canal. Apart from lifting the prolapsing hemorrhoids, blood supply to hemorrhoidal tissue is also interrupted. A recent meta-analysis comparing surgical outcomes between SH and hemorrhoidectomy, which included 27 randomized, controlled trials with 2279 procedures, showed that SH was associated with less pain, earlier return of bowel function, shorter hospital stay, earlier return to normal activities, and better wound healing, as well as higher degree of patient satisfaction[ 30 ]. However, in the longer term, SH was associated with a higher rate of prolapse[ 30 , 31 , 75 ]. Considering the recurrence rate, cost of stapling device and potential serious complications including rectovaginal fistula[ 76 ] and rectal stricture[ 77 , 78 ], SH is generally reserved for patients with circumferential prolapsing hemorrhoids and having ≥ 3 lesions of advanced internal hemorrhoids.

These two recent surgical options, DGHAL and SH, aim to correct the pathophysiology of hemorrhoids by reducing blood flow to the anal canal (dearterialization) and eliminating anorectal mucosal prolapse (reposition), respectively. A recent retrospective study of 18-mo outcomes of DGHAL ( n = 51) and SH ( n = 63) for grade III hemorrhoids revealed that both procedures were safe and effective. DGHAL had less pain, shorter hospital stay, and faster functional recovery; however, it was associated with higher recurrence rate and lower patient satisfaction rating[ 79 ]. Lately, a smaller prospective trial comparing DGHAL to SH for grade II-III hemorrhoids showed similar short-term and long-term outcomes of the two procedures[ 80 ]. Nevertheless, patients undergoing DGHAL returned to work quicker, and had fewer complication rates than those receiving SH.

Therapeutic treatment of hemorrhoids ranges from dietary and lifestyle modification to radical surgery, depending on degree and severity of symptoms. Although surgery is an effective treatment of hemorrhoids, it is reserved for advanced disease and it can be associated with appreciable complications. Meanwhile, non-operative treatments are not fully effective, in particular those of topical or pharmacological approach. Hence, improvements in our understanding of the pathophysiology of hemorrhoids are needed to prompt the development of novel and innovative methods for the treatment of hemorrhoids.

Supported by Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand

Peer reviewer: Rasmus Goll, MD, Department of Gastro-enterology, University Hospital of North Norway, 9038 Tromso, Norway

S- Editor Gou SX L- Editor Logan S E- Editor Li JY

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Pathophysiology of Hemorrhoids

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June 13, 2019

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Applied anatomy of hemorrhoids

Pathophysiology of hemorrhoids

Symptoms & clinical evaluation

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• Blood Supply to Anorectal Region
• Anal Cushions & Hemorrhoids
• Types of hemorrhoids
• Histology of Hemorrhoids

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• Sliding anal cushions/ Loss of fixation: Presenting symptom: Prolapse
• Rectal redundancy/ Internal rectal prolapse: Presenting symptom: Circumferential prolapse
• Vascular abnormalities: Presenting symptom: Bleeding

A few slides are dedicated to Hemorrhoids Pathophysiology & Risk Factors and finally, the last part is about the Symptoms and Clinical evaluation of hemorrhoids.

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Digestive Problems: Hemorrhoids

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Hemorrhoids are swollen and inflamed veins in the rectum or anus. They can occur both internally, affecting the lining of the rectum and externally, under the skin around the anus. While there can be numerous causes for hemorrhoids, including chronic constipation or straining during bowel movements, pregnancy is a common trigger due to increased pressure on veins in the lower part of the body. Speak about them in more detail with this template designed specifically for medical presentations!

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Item   Count   Loading… Times Cited (350) This review discusses the pathophysiology, epidemiology, risk factors, classification, clinical evaluation, and current non-operative and operative treatment of hemorrhoids. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoids. It appears that the dysregulation of the vascular tone and vascular hyperplasia might play an important role in hemorrhoidal development, and could be a potential target for medical treatment. In most instances, hemorrhoids are treated conservatively, using many methods such as lifestyle modification, fiber supplement, suppository-delivered anti-inflammatory drugs, and administration of venotonic drugs. Non-operative approaches include sclerotherapy and, preferably, rubber band ligation. An operation is indicated when non-operative approaches have failed or complications have occurred. Several surgical approaches for treating hemorrhoids have been introduced including hemorrhoidectomy and stapled hemorrhoidopexy, but postoperative pain is invariable. Some of the surgical treatments potentially cause appreciable morbidity such as anal stricture and incontinence. The applications and outcomes of each treatment are thoroughly discussed. Citation: Lohsiriwat V. Hemorrhoids: From basic pathophysiology to clinical management.  World J Gastroenterol  2012; 18(17): 2009-2017 URL: https://www.wjgnet.com/1007-9327/full/v18/i17/2009.htm DOI: https://dx.doi.org/10.3748/wjg.v18.i17.2009 Hemorrhoids are a very common anorectal condition defined as the symptomatic enlargement and distal displacement of the normal anal cushions. They affect millions of people around the world, and represent a major medical and socioeconomic problem. Multiple factors have been claimed to be the etiologies of hemorrhoidal development, including constipation and prolonged straining. The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a paramount finding of hemorrhoidal disease[ 1 ]. An inflammatory reaction[ 2 ] and vascular hyperplasia[ 3 , 4 ] may be evident in hemorrhoids. This article firstly reviewed the pathophysiology and other clinical backgrounds of hemorrhoidal disease, followed by the current approaches to non-operative and operative management. The exact pathophysiology of hemorrhoidal development is poorly understood. For years the theory of varicose veins, which postulated that hemorrhoids were caused by varicose veins in the anal canal, had been popular but now it is obsolete because hemorrhoids and anorectal varices are proven to be distinct entities. In fact, patients with portal hypertension and varices do not have an increased incidence of hemorrhoids[ 5 ]. Today, the theory of sliding anal canal lining is widely accepted[ 6 ]. This proposes that hemorrhoids develop when the supporting tissues of the anal cushions disintegrate or deteriorate. Hemorrhoids are therefore the pathological term to describe the abnormal downward displacement of the anal cushions causing venous dilatation. There are typically three major anal cushions, located in the right anterior, right posterior and left lateral aspect of the anal canal, and various numbers of minor cushions lying between them[ 7 ] (Figure 1 ). The anal cushions of patients with hemorrhoids show significant pathological changes. These changes include abnormal venous dilatation, vascular thrombosis, degenerative process in the collagen fibers and fibroelastic tissues, distortion and rupture of the anal subepithelial muscle (Figure 2 ). In addition to the above findings, a severe inflammatory reaction involving the vascular wall and surrounding connective tissue has been demonstrated in hemorrhoidal specimens, with associated mucosal ulceration, ischemia and thrombosis[ 2 ]. Several enzymes or mediators involving the degradation of supporting tissues in the anal cushions have been studied. Among these, matrix metalloproteinase (MMP), a zinc-dependent proteinase, is one of the most potent enzymes, being capable of degrading extracellular proteins such as elastin, fibronectin, and collagen. MMP-9 was found to be over-expressed in hemorrhoids, in association with the breakdown of elastic fibers[ 8 ]. Activation of MMP-2 and MMP-9 by thrombin, plasmin or other proteinases resulted in the disruption of the capillary bed and promotion of angioproliferative activity of transforming growth factor β (TGF-β)[ 9 ]. Recently, increased microvascular density was found in hemorrhoidal tissue, suggesting that neovascularization might be another important phenomenon of hemorrhoidal disease. In 2004, Chung et al [ 4 ] reported that endoglin (CD105), which is one of the binding sites of TGF-β and is a proliferative marker for neovascularization, was expressed in more than half of hemorrhoidal tissue specimens compared to none taken from the normal anorectal mucosa. This marker was prominently found in venules larger than 100 μm. Moreover, these workers found that microvascular density increased in hemorrhoidal tissue especially when thrombosis and stromal vascular endothelial growth factors (VEGF) were present. Han et al [ 8 ] also demonstrated that there was a higher expression of angiogenesis-related protein such as VEGF in hemorrhoids. Regarding the study of morphology and hemodynamics of the anal cushions and hemorrhoids, Aigner et al [ 3 , 10 ] found that the terminal branches of the superior rectal artery supplying the anal cushion in patients with hemorrhoids had a significantly larger diameter, greater blood flow, higher peak velocity and acceleration velocity, compared to those of healthy volunteers. Moreover, an increase in arterial caliber and flow was well correlated with the grades of hemorrhoids. These abnormal findings still remained after surgical removal of the hemorrhoids, confirming the association between hypervascularization and the development of hemorrhoids. Using an immunohistochemical approach, Aigner et al [ 3 ] also identified a sphincter-like structure, formed by a thickened tunica media containing 5-15 layers of smooth muscle cells, between the vascular plexus within the subepithelial space of the anal transitional zone in normal anorectal specimens. Unlike the normal specimens, hemorrhoids contained remarkably dilated, thin-walled vessels within the submucosal arteriovenous plexus, with absent or nearly-flat sphincter-like constriction on the vessels. These investigators concluded that a smooth muscle sphincter in the arteriovenous plexus helps in reducing the arterial inflow, thus facilitating an effective venous drainage. Aigner et al [ 3 ] then proposed that, if this mechanism is impaired, hyperperfusion of the arteriovenous plexus will lead to the formation of hemorrhoids. Based on the histological findings of abnormal venous dilatation and distortion in hemorrhoids, dysregulation of the vascular tone might play a role in hemorrhoidal development. Basically, vascular smooth muscle is regulated by the autonomic nervous system, hormones, cytokines and overlying endothelium. Imbalance between endothelium-derived relaxing factors (such as nitric oxide, prostacyclin, and endothelium-derived hyperpolarizing factor) and endothelium-derived vasoconstricting factors (such as reactive oxygen radicals and endothelin) causes several vascular disorders[ 11 ]. In hemorrhoids, nitric oxide synthase, an enzyme which synthesizes nitric oxide from L-arginine, was reported to increase significantly[ 8 ]. Several physiological changes in the anal canal of patients with hemorrhoids have been observed. Sun et al [ 12 ] revealed that resting anal pressure in patients with non-prolapsing or prolapsing hemorrhoids was much higher than in normal subjects, whereas there was no significant change in the internal sphincter thickness. Ho et al [ 13 ] performed anorectal physiological studies in 24 patients with prolapsed hemorrhoids and compared with results in 13 sex- and age-matched normal subjects. Before operation, those with hemorrhoids had significantly higher resting anal pressures, lower rectal compliance, and more perineal descent. The abnormalities found reverted to the normal range within 3 mo after hemorrhoidectomy, suggesting that these physiological changes are more likely to be an effect, rather than the cause, of hemorrhoidal disease. Although hemorrhoids are recognized as a very common cause of rectal bleeding and anal discomfort, the true epidemiology of this disease is unknown because patients have a tendency to use self-medication rather than to seek proper medical attention. An epidemiologic study by Johanson et al [ 14 ] in 1990 showed that 10 million people in the United States complained of hemorrhoids, corresponding to a prevalence rate of 4.4%. In both sexes, peak prevalence occurred between age 45-65 years and the development of hemorrhoids before the age of 20 years was unusual. Whites and higher socioeconomic status individuals were affected more frequently than blacks and those of lower socioeconomic status. However, this association may reflect differences in health-seeking behavior rather than true prevalence. In the United Kingdom, hemorrhoids were reported to affect 13%-36% of the general population[ 1 , 15 ]. However, this estimation may be higher than actual prevalence because the community-based studies mainly relied on self-reporting and patients may attribute any anorectal symptoms to hemorrhoids. Constipation and prolonged straining are widely believed to cause hemorrhoids because hard stool and increased intraabdominal pressure could cause obstruction of venous return, resulting in engorgement of the hemorrhoidal plexus[ 1 ]. Defecation of hard fecal material increases shearing force on the anal cushions. However, recent evidence questions the importance of constipation in the development of this common disorder[ 14 , 16 , 17 ]. Many investigators have failed to demonstrate any significant association between hemorrhoids and constipation, whereas some reports suggested that diarrhea is a risk factor for the development of hemorrhoids[ 16 ]. Increase in straining for defecation may precipitate the development of symptoms such as bleeding and prolapse in patients with a history of hemorrhoidal disease. Pregnancy can predispose to congestion of the anal cushion and symptomatic hemorrhoids, which will resolve spontaneously soon after birth. Many dietary factors including low fiber diet, spicy foods and alcohol intake have been implicated, but reported data are inconsistent[ 1 ]. A hemorrhoid classification system is useful not only to help in choosing between treatments, but also to allow the comparison of therapeutic outcomes among them. Hemorrhoids are generally classified on the basis of their location and degree of prolapse. Internal hemorrhoids originate from the inferior hemorrhoidal venous plexus above the dentate line and are covered by mucosa, while external hemorrhoids are dilated venules of this plexus located below the dentate line and are covered with squamous epithelium. Mixed (interno-external) hemorrhoids arise both above and below the dentate line. For practical purposes, internal hemorrhoids are further graded based on their appearance and degree of prolapse, known as Goligher’s classification: (1) First-degree hemorrhoids (grade I): The anal cushions bleed but do not prolapse; (2) Second-degree hemorrhoids (grade II): The anal cushions prolapse through the anus on straining but reduce spontaneously; (3) Third-degree hemorrhoids (grade III): The anal cushions prolapse through the anus on straining or exertion and require manual replacement into the anal canal; and (4) Fourth-degree hemorrhoids (grade IV): The prolapse stays out at all times and is irreducible. Acutely thrombosed, incarcerated internal hemorrhoids and incarcerated, thrombosed hemorrhoids involving circumferential rectal mucosal prolapse are also fourth-degree hemorrhoids[ 18 ]. Some authors proposed classifications based on anatomical findings of hemorrhoidal position, described as primary (at the typical three sites of the anal cushions), secondary (between the anal cushions), or circumferential, and based on symptoms described as prolapsing and non-prolapsing[ 19 ]. However, these classifications are in less widespread use. The most common manifestation of hemorrhoids is painless rectal bleeding associated with bowel movement, described by patients as blood drips into toilet bowl. The blood is typically bright red as hemorrhoidal tissue has direct arteriovenous communication[ 3 ]. Positive fecal occult blood or anemia should not be attributed to hemorrhoids until the colon is adequately evaluated especially when the bleeding is atypical for hemorrhoids, when no source of bleeding is evident on anorectal examination, or when the patient has significant risk factors for colorectal neoplasia[ 18 ]. Prolapsing hemorrhoids may cause perineal irritation or anal itching due to mucous secretion or fecal soiling. A feeling of incomplete evacuation or rectal fullness is also reported in patients with large hemorrhoids. Pain is not usually caused by the hemorrhoids themselves unless thrombosis has occurred, particularly in an external hemorrhoid or if a fourth-degree internal hemorrhoid becomes strangulated. Anal fissure and perianal abscess are more common causes of anal pain in hemorrhoidal patients. The definite diagnosis of hemorrhoidal disease is based on a precise patient history and careful clinical examination. Assessment should include a digital examination and anoscopy in the left lateral position. The perianal area should be inspected for anal skin tags, external hemorrhoid, perianal dermatitis from anal discharge or fecal soiling, fistula-in-ano and anal fissure. Some physicians prefer patients sitting and straining in the squatting position to watch for the prolapse. Although internal hemorrhoids cannot be palpated, digital examination will detect abnormal anorectal mass, anal stenosis and scar, evaluate anal sphincter tone, and determine the status of prostatic hypertrophy which may be the reason for straining as this aggravates descent of the anal cushions during micturition. Hemorrhoidal size, location, severity of inflammation and bleeding should be noted during anoscopy. Intrarectal retroflexion of the colonoscope or transparent anoscope with flexible endoscope also allow excellent visualization of the anal canal and hemorrhoid, and permit recording pictures[ 20 ]. Therapeutic treatment of hemorrhoids ranges from die-tary and lifestyle modification to radical surgery, depending on degree and severity of symptoms[ 21 , 22 ]. The current management of internal hemorrhoids is illustrated in Table 1 . In addition, selected meta-analyses showing various treatment options of hemorrhoidal disease are shown in Table 2 [ 23 - 32 ]. I II III IV Dietary and lifestyle modification × × × × × Medical treatment × × ×-selected Non-operative treatment Sclerotherapy × × Infrared coagulation × × Radiofrequency ablation × × Rubber band ligation × × ×-selected Operative treatment Plication × × DGHAL × × Hemorrhoidectomy ×-selected × × ×-emergency Stapled hemorrhoidopexy × × Johanson [ ] IC, IS and RBL 5 (863) RBL had greater long-term efficacy, but led to a higher incidence of post-treatment pain. IC was associated with both fewer and less severe complications MacRae [ ] IC, IS, RBL, manual anal dilation and hemorrhoidectomy 18 (1952) Hemorrhoidectomy was more effective than manual anal dilation and RBL, but more pain and complications. RBL had greater efficacy than IS for treating grade I-III hemorrhoids, with no difference in the complication rate. Patients treated with IC or IS were more likely to require further therapy Shanmugam [ ] RBL hemorrhoidectomy 3 (202) Hemorrhoidectomy was superior to RBL for the long-term treatment of grade III, not grade II, hemorrhoids. Although hemorrhoidectomy had more pain, higher complications and more time off work, patient satisfaction and acceptance of the two treatment modalities seems to be similar Alonso-Coello [ ] Fiber no therapy 7 (378) Fiber reduced the risk of bleeding and persisting by 50% and 47%, respectively, but it had no significant effect on pain and prolapse Alonso-Coello [ ] Oral flavonoids placebo or no therapy 14 (1514) Flavonoids reduced the risk of bleeding, pain, persisting symptoms and recurrence by 67%, 65%, 58% and 47%, respectively Ho [ ] Closed open hemorrhoidectomy 6 (686) Closed hemorrhoidectomy had faster wound healing but longer operating time. There was no difference in treatment efficacy, pain, complication and hospital stay between the two operations Nienhuijs [ ] Conventional ligasure hemorrhoidectomy 12 (1142) Ligasure hemorrhoidectomy resulted in significantly shorter operative time, less early postoperative pain, earlier recovery, without any difference in recurrent bleeding or incontinence Burch [ ] Hemorrhoidectomy SH 27 (2279) SH had less postoperative pain, shorter operative time, shorter hospital stay, and shorter convalescence, but a higher rate of prolapse and reintervention for prolapse Giordano [ ] Hemorrhoidectomy SH (minimum follow-up of 1 yr) 15 (1201) SH had a significantly higher incidence of recurrences and additional operations Gan [ ] Various TCMH another TCMH or Western medicines 9 (1822) TCMHs significantly improved overall symptoms and bleeding as well as decreased the inflammation of perianal mucosa Since shearing action of passing hard stool on the anal mucosa may cause damage to the anal cushions and lead to symptomatic hemorrhoids, increasing intake of fiber or providing added bulk in the diet might help eliminate straining during defecation. In clinical studies of hemorrhoids, fiber supplement reduced the risk of persisting symptoms and bleeding by approximately 50%, but did not improve the symptoms of prolapse, pain, and itching[ 26 ]. Fiber supplement is therefore regarded as an effective treatment in non-prolapsing hemorrhoids; however, it could take up to 6 wk for a significant improvement to be manifest[ 33 ]. As fiber supplements are safe and cheap, they remain an integral part of both initial treatment and of a regimen following other therapeutic modalities of hemorrhoids. Lifestyle modification should also be advised to any patients with any degree of hemorrhoids as a part of treatment and as a preventive measure. These changes include increasing the intake of dietary fiber and oral fluids, reducing consumption of fat, having regular exercise, improving anal hygiene, abstaining from both straining and reading on the toilet, and avoiding medication that causes constipation or diarrhea. Oral flavonoids : These venotonic agents were first described in the treatment of chronic venous insufficiency and edema. They appeared to be capable of increasing vascular tone, reducing venous capacity, decreasing capillary permeability[ 34 ], and facilitating lymphatic drainage[ 35 ] as well as having anti-inflammatory effects[ 36 ]. Although their precise mechanism of action remains unclear, they are used as an oral medication for hemorrhoidal treatment, particularly in Europe and Asia. Micronized purified flavonoid fraction (MPFF), consisting of 90% diosmin and 10% hesperidin, is the most common flavonoid used in clinical treatment[ 27 ]. The micronization of the drug to particles of less than 2 μm not only improved its solubility and absorption, but also shortened the onset of action. A recent meta-analysis of flavonoids for hemorrhoidal treatment, including 14 randomized trials and 1514 patients, suggested that flavonoids decreased risk of bleeding by 67%, persistent pain by 65% and itching by 35%, and also reduced the recurrence rate by 47%[ 27 ]. Some investigators reported that MPFF can reduce rectal discomfort, pain and secondary hemorrhage following hemorrhoidectomy[ 37 ]. Oral calcium dobesilate : This is another venotonic drug commonly used in diabetic retinopathy and chronic venous insufficiency as well as in the treatment of acute symptoms of hemorrhoids[ 38 ]. It was demonstrated that calcium dobesilate decreased capillary permeability, inhibited platelet aggregation and improved blood viscosity; thus resulting in reduction of tissue edema[ 39 ]. A clinical trial of hemorrhoid treatment showed that calcium dobesilate, in conjunction with fiber supplement, provided an effective symptomatic relief from acute bleeding, and it was associated with a significant improvement in the inflammation of hemorrhoids[ 40 ]. Topical treatment: The primary objective of most topical treatment aims to control the symptoms rather than to cure the disease. Thus, other therapeutic treatments could be subsequently required. A number of topical preparations are available including creams and suppositories, and most of them can be bought without a prescription. Strong evidence supporting the true efficacy of these drugs is lacking. These topical medications can contain various ingredients such as local anesthesia, corticosteroids, antibiotics and anti-inflammatory drugs[ 41 ]. Topical treatment may be effective in selected groups of hemorrhoidal patients. For instance, Tjandra et al [ 42 ] showed a good result with topical glyceryl trinitrate 0.2% ointment for relieving hemorrhoidal symptoms in patients with low-grade hemorrhoids and high resting anal canal pressures. However, 43% of the patients experienced headache during the treatment. Perrotti et al [ 43 ] reported the good efficacy of local application of nifedipine ointment in treatment of acute thrombosed external hemorrhoids. It is worth noting that the effect of topical application of nitrite and calcium channel blocker on the symptomatic relief of hemorrhoids may be a consequence of their relaxation effect on the internal anal sphincter, rather than on the hemorrhoid tissue per se where one might anticipate a predominantly vasodilator effect. Apart from topical medication influencing tone of the internal anal sphincter, some topical treatment targets vasoconstriction of the vascular channels within hemorrhoids such as Preparation-H ® (Pfizer, United States), which contains 0.25% phenylephrine, petrolatum, light mineral oil, and shark liver oil. Phenylephrine is a vasoconstrictor having preferential vasopressor effect on the arterial site of circulation, whereas the other ingredients are considered protectants. Preparation-H is available in many forms, including ointment, cream, gel, suppositories, and medicated and portable wipes[ 44 ]. It provides temporary relief of acute symptoms of hemorrhoids, such as bleeding and pain on defecation. Sclerotherapy: This is currently recommended as a treatment option for first- and second-degree hemorrhoids. The rationale of injecting chemical agents is to create a fixation of mucosa to the underlying muscle by fibrosis. The solutions used are 5% phenol in oil, vegetable oil, quinine, and urea hydrochloride or hypertonic salt solution[ 22 ]. It is important that the injection be made into submucosa at the base of the hemorrhoidal tissue and not into the hemorrhoids themselves; otherwise, it can cause immediate transient precordial and upper abdominal pain[ 45 ]. Misplacement of the injection may also result in mucosal ulceration or necrosis, and rare septic complications such as prostatic abscess and retroperitoneal sepsis[ 46 ]. Antibiotic prophylaxis is indicated for patients with predisposing valvular heart disease or immunodeficiency because of the possibility of bacteremia after sclerotherapy[ 47 ]. Rubber band ligation: Rubber band ligation (RBL) is a simple, quick, and effective means of treating first- and second-degree hemorrhoids and selected patients with third-degree hemorrhoids. Ligation of the hemorrhoidal tissue with a rubber band causes ischemic necrosis and scarring, leading to fixation of the connective tissue to the rectal wall. Placement of rubber band too close to the dentate line may cause severe pain due to the presence of somatic nerve afferents and requires immediate removal. RBL is safely performed in one or more than one place in a single session[ 48 ] with one of several commercially available instruments, including hemorrhoid ligator rectoscope[ 49 ] and endoscopic ligator[ 50 ] which use suction to draw the redundant tissue in to the applicator to make the procedure a one-person effort. The most common complication of RBL is pain or rectal discomfort, which is usually relieved by warm sitz baths, mild analgesics and avoidance of hard stool by taking mild laxatives or bulk-forming agents. Other complications include minor bleeding from mucosal ulceration, urinary retention, thrombosed external hemorrhoids, and extremely rarely, pelvic sepsis. The patients should stop taking anticoagulants for one week before and two weeks after RBL. Infrared coagulation: The infrared coagulator produces infrared radiation which coagulates tissue and evaporizes water in the cell, causing shrinkage of the hemorrhoid mass. A probe is applied to the base of the hemorrhoid through the anoscope and the recommended contact time is between 1.0-1.5 s, depending on the intensity and wavelength of the coagulator[ 51 ]. The necrotic tissue is seen as a white spot after the procedure and eventually heals with fibrosis. Compared with sclerotherapy, infrared coagulation (IRC) is less technique-dependent and avoids the potential complications of misplaced sclerosing injection[ 22 ]. Although IRC is a safe and rapid procedure, it may not be suitable for large, prolapsing hemorrhoids. Radiofrequency ablation: Radiofrequency ablation (RFA) is a relatively new modality of hemorrhoidal treatment. A ball electrode connected to a radiofrequency generator is placed on the hemorrhoidal tissue and causes the contacting tissue to be coagulated and evaporized[ 52 ]. By this method, vascular components of hemorrhoids are reduced and hemorrhoidal mass will be fixed to the underlying tissue by subsequent fibrosis. RFA can be performed on an outpatient basis and via an anoscope similar to sclerotherapy. Its complications include acute urinary retention, wound infection, and perianal thrombosis. Although RFA is a virtually painless procedure, it is associated with a higher rate of recurrent bleeding and prolapse[ 53 ]. Cryotherapy: Cryotherapy ablates the hemorrhoidal tissue with a freezing cryoprobe. It has been claimed to cause less pain because sensory nerve endings are destroyed at very low temperature. However, several clinical trials revealed that it was associated with prolonged pain, foul-smelling discharge and a high rate of persistent hemorrhoidal mass[ 54 ]. It is therefore rarely used. There are two meta-analyses comparing outcomes among the three common non-operative treatments of hemorrhoids (sclerotherapy, RBL and IRC)[ 23 , 24 ]. These two studies demonstrated that RBL resulted in the fewest recurrent symptoms of hemorrhoids and the lowest rate of retreatment, but that it led to a significantly higher incidence of pain following the procedure. Hence, RBL could be recommended as the initial non-operative modality for treatment of grade I-III hemorrhoids. In a British survey of almost 900 general and colorectal surgeons[ 55 ], RBL was the most common procedure performed, following by sclerotherapy and hemorrhoidectomy. An operation is indicated when non-operative approaches have failed or complications have occurred. Different philosophies regarding the pathogenesis of hemorrhoidal disease creates different surgical approaches (Table 3 ). Sliding anal cushions Hemorrhoids develop when the supporting tissues of the anal cushions disintegrate or deteriorate Hemorrhoidectomy, plication Rectal redundancy Hemorrhoidal prolapse is associated with an internal rectal prolapse Stapled hemorrhoidopexy Vascular abnormality Hyperperfusion of arteriovenous plexus within anal cushion results in the formation of hemorrhoids Doppler-guided hemorrhoidal artery ligation Hemorrhoidectomy: Excisional hemorrhoidectomy is the most effective treatment for hemorrhoids with the lowest rate of recurrence compared to other modalities[ 24 ]. It can be performed using scissors, diathermy[ 56 , 57 ], or vascular-sealing device such as Ligasure (Covidien, United States)[ 29 , 58 ] and Harmonic scalpel (Ethicon Endosurgery, United States)[ 59 , 60 ]. Excisional hemorrhoidectomy can be performed safely under perianal anesthetic infiltration as an ambulatory surgery[ 61 , 62 ]. Indications for hemorrhoidectomy include failure of non-operative management, acute complicated hemorrhoids such as strangulation or thrombosis, patient preference, and concomitant anorectal conditions such as anal fissure or fistula-in-ano which require surgery[ 18 ]. In clinical practice, the third-degree or fourth-degree internal hemorrhoids are the main indication for hemorrhoidectomy. A major drawback of hemorrhoidectomy is postoperative pain[ 62 ]. There has been evidence that Ligasure hemorrhoidectomy results in less postoperative pain, shorter hospitalization, faster wound healing and convalescence compared to scissors or diathermy hemorrhoidectomy[ 63 - 65 ]. Other postoperative complications include acute urinary retention (2%-36%), postoperative bleeding (0.03%-6%), bacteremia and septic complications (0.5%-5.5%), wound breakdown, unhealed wound, loss of anal sensation, mucosa prolapse, anal stricture (0%-6%), and even fecal incontinence (2%-12%)[ 66 - 69 ]. Recent evidence has suggested that hemorrhoidal specimens can be exempt from pathological examination if no malignancy is suspected[ 70 ]. Plication: Plication is capable of restoring anal cushions to their normal position without excision. This procedure involves oversewing of hemorrhoidal mass and tying a knot at the uppermost vascular pedicle. However, there are still a number of potential complications following this procedure such as bleeding and pelvic pain[ 21 ]. Doppler-guided hemorrhoidal artery ligation: A new technique based on doppler-guided ligation of the terminal branches of the superior hemorrhoidal artery was introduced in 1995 as an alternative to hemorrhoidectomy[ 71 ]. Doppler-guided hemorrhoidal artery ligation (DGHAL) has become increasingly popular in Europe. The rationale of this treatment was later supported by the findings from vascular studies[ 3 , 10 ], which demonstrated that patients with hemorrhoids had increased caliber and arterial blood flow of the terminal branch of the superior rectal arteries. Therefore, ligating the arterial supply to hemorrhoidal tissue by suture ligation may improve hemorrhoidal symptoms. DGHAL is most effective for second- or third-degree hemorrhoids. Notably, DGHAL may not improve prolapsing symptoms in advanced hemorrhoids. Short-term outcomes and 1-year recurrence rates of DGHAL did not differ from those of conventional hemorrhoidectomy[ 72 ]. Given the fact that there is the possibility of revascularization and recurrence of symptomatic hemorrhoids, further studies on the long-term outcomes of DGHAL are still required[ 73 ]. Stapled hemorrhoidopexy: Stapled hemorrhoidopexy (SH) has been introduced since 1998[ 74 ]. A circular stapling device is used to excise a ring of redundant rectal mucosa proximal to hemorrhoids and resuspend the hemorrhoids back within the anal canal. Apart from lifting the prolapsing hemorrhoids, blood supply to hemorrhoidal tissue is also interrupted. A recent meta-analysis comparing surgical outcomes between SH and hemorrhoidectomy, which included 27 randomized, controlled trials with 2279 procedures, showed that SH was associated with less pain, earlier return of bowel function, shorter hospital stay, earlier return to normal activities, and better wound healing, as well as higher degree of patient satisfaction[ 30 ]. However, in the longer term, SH was associated with a higher rate of prolapse[ 30 , 31 , 75 ]. Considering the recurrence rate, cost of stapling device and potential serious complications including rectovaginal fistula[ 76 ] and rectal stricture[ 77 , 78 ], SH is generally reserved for patients with circumferential prolapsing hemorrhoids and having ≥ 3 lesions of advanced internal hemorrhoids. These two recent surgical options, DGHAL and SH, aim to correct the pathophysiology of hemorrhoids by reducing blood flow to the anal canal (dearterialization) and eliminating anorectal mucosal prolapse (reposition), respectively. A recent retrospective study of 18-mo outcomes of DGHAL ( n = 51) and SH ( n = 63) for grade III hemorrhoids revealed that both procedures were safe and effective. DGHAL had less pain, shorter hospital stay, and faster functional recovery; however, it was associated with higher recurrence rate and lower patient satisfaction rating[ 79 ]. Lately, a smaller prospective trial comparing DGHAL to SH for grade II-III hemorrhoids showed similar short-term and long-term outcomes of the two procedures[ 80 ]. Nevertheless, patients undergoing DGHAL returned to work quicker, and had fewer complication rates than those receiving SH. Therapeutic treatment of hemorrhoids ranges from dietary and lifestyle modification to radical surgery, depending on degree and severity of symptoms. Although surgery is an effective treatment of hemorrhoids, it is reserved for advanced disease and it can be associated with appreciable complications. Meanwhile, non-operative treatments are not fully effective, in particular those of topical or pharmacological approach. Hence, improvements in our understanding of the pathophysiology of hemorrhoids are needed to prompt the development of novel and innovative methods for the treatment of hemorrhoids. 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Case suffers from hemorrhoids? 😥 #caseoh #caseohclips Internal Hemorrhoids And External Hemorrhoids What is Hemorrhoids Case Study Of Haemorrhoids ! case study with five diagnosis ! assesment on case study! hemrrohids The Case for Open Educational Resources COMMENTS PPT External Hemorrhoids: These are under the skin Laser treatment for piles around the anus and can be painful. Common symptoms include: Itching and irritation in the anal area. Pain or discomfort, especially during sitting or bowel movements. Swelling or a lump near the anus. Diagnosis: Diagnosing hemorrhoids typically involves a combination of ... PPT Presentation Transcript. HEMORRHOIDS Nga Vu, MD PGY3 Emory Family Medicine 11/18/10. Causes • chronic straining secondary to constipation • diarrhea • tenesmus • long periods trying to defecate • common during pregnancy and child-birth. Anatomy • Dentate line, divides hemorrhoids anatomically into internal (above the junction) and ... Review of Hemorrhoid Disease: Presentation and Management In this review, the authors will discuss the anatomy, pathophysiology, clinical presentation, and management of hemorrhoid disease. Keywords: hemorrhoids, rectal bleeding, thrombosis, management. Hemorrhoid disease is the fourth leading outpatient gastrointestinal diagnosis, accounting for ∼3.3 million ambulatory care visits in the United ... Management of internal hemorrhoids by Kshara karma: An educational case In present day practice, application of Kshara is found to be a safe, efficacious, and cost-effective method for management of internal hemorrhoids. Compilation of case reports and clinical studies are needed to standardize the treatment protocol and define outcome measures. In this way, comprehensive treatment guidelines can be formulated. Rethinking What We Know About Hemorrhoids The burden of hemorrhoids. There has only been one national survey of hemorrhoids in the US and that survey was conducted in 1989. In a digestive disease supplement to the National Health Interview Survey, participants were asked if a doctor had ever diagnosed them with hemorrhoids. 6 The survey data were extrapolated to the US population. An estimated 23 million adults (13% US population ... Hemorrhoids Clinical Presentation Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology. 1990 Feb. 98(2):380-6. [QxMD MEDLINE Link]. Johanson JF, Sonnenberg A. Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents. Am J Gastroenterol. 1994 Nov. 89(11):1981-6. Case-based learning: haemorrhoids Understand that there are different presentations of haemorrhoids. Haemorrhoids are clusters of vascular tissue, smooth muscle and connective tissue arranged in three columns along the anal canal [1] . In healthy individuals, they act as cushions that help maintain continence [1] . Although haemorrhoids — or 'piles' as they are otherwise ... Hemorrhoids Why hemorrhoids become symptomatic is uncertain. In an Austrian observational study involving adults who underwent routine screening colonoscopy, approximately 39% had visibly enlarged ... Surgical Procedure for Hemorrhoids Clinical Case Presentation Hemorrhoids are swollen veins in the anus or lower rectum. They are pretty common in adults and although they are mildly uncomfortable, they can sometimes be too painful and might need surgical intervention. Speak all about this procedure with this template for a clinical case! The design is super cool and modern and it has everything you need ... (PDF) A Case Study of Four Hemorrhoid Patients Treated by Korean PDF | On May 30, 2018, Jin-hyuk Lee and others published A Case Study of Four Hemorrhoid Patients Treated by Korean Medical Treatment | Find, read and cite all the research you need on ResearchGate Anatomy, Physiology, and Pathophysiology of Hemorrhoids 1 Introduction. The understanding of anatomy, physiology, and pathophysiology of hemorrhoids is fundamental to selecting an appropriate treatment of hemor-rhoids, improving treatment outcomes, develop-ing novel methods for managing hemorrhoids, and preventing recurrent diseases. This chapter deals with some essential knowledge and current views ... Hemorrhoids: From basic pathophysiology to clinical management Abstract. This review discusses the pathophysiology, epidemiology, risk factors, classification, clinical evaluation, and current non-operative and operative treatment of hemorrhoids. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. The most common symptom of hemorrhoids is rectal ... Pathophysiology of Hemorrhoids You will also learn about the different causes of hemorrhoids formation: Sliding anal cushions/ Loss of fixation: Presenting symptom: Prolapse. Rectal redundancy/ Internal rectal prolapse: Presenting symptom: Circumferential prolapse. Vascular abnormalities: Presenting symptom: Bleeding. A few slides are dedicated to Hemorrhoids Pathophysiology ... Digestive Problems: Hemorrhoids Free Google Slides theme, PowerPoint template, and Canva presentation template. Hemorrhoids are swollen and inflamed veins in the rectum or anus. They can occur both internally, affecting the lining of the rectum and externally, under the skin around the anus. While there can be numerous causes for hemorrhoids, including chronic constipation or ... PDF Efficacy of Homoeopathy in Hemorrhoids Objective: this study aims to access efficacy of Homoeopathic medicines in cases of Hemorrhoids. Result: the use of constitutional homoeopathic remedy has a beneficial effect in cases of Hemorrhoids. Conclusion: The findings of the above study concluded that 94% of the cases responded well to the indicated Homoeopathic similimum. Hemorrhoids: From basic pathophysiology to clinical management Telephone: +66-0-24198077 Fax: +66-0-24115009. This review discusses the pathophysiology, epidemiology, risk factors, classification, clinical evaluation, and current non-operative and operative treatment of hemorrhoids. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. assignment essay homework paper phd report resume review speech thesis