Hemorrhoid
From Wikipedia, the free encyclopedia
Hemorrhoids (US English) or
haemorrhoids (
UK 
/ˈhɛmərɔɪdz/), are
vascular structures in the
anal canal which help with stool control.
[1][2] They become
pathological or
piles[3] when
swollen or
inflamed. In their physiological state, they act as a cushion composed of
arterio-venous channels and
connective tissue.
The symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless
rectal bleeding while external hemorrhoids may produce few symptoms or if
thrombosed significant pain and swelling in the area of the
anus.
Many people incorrectly refer to any symptom occurring around the
anal-rectal area as "hemorrhoids" and serious causes of the symptoms
should be ruled out.
[4]
While the exact cause of hemorrhoids remains unknown, a number of
factors which increase intra-abdominal pressure, in particular
constipation, are believed to play a role in their development.
Initial treatment for mild to moderate disease consists of increasing
fiber intake, oral fluids to maintain hydration,
NSAIDs
to help with the pain, and rest. A number of minor procedures may be
performed if symptoms are severe or do not improve with conservative
management. Surgery is reserved for those who fail to improve following
these measures. Up to half of people may experience problems with
hemorrhoids at some point in their life. Outcomes are usually good.
Signs and symptoms
Internal and external hemorrhoids may present differently; however, many people may have a combination of the two.
[2] Bleeding significant enough to cause
anemia is rare,
[5] and life threatening bleeding is even more uncommon.
[6] Many people feel embarrassed when facing the problem
[5] and frequently seek medical care only when the case is advanced.
[2]
External
If not
thrombosed, external hemorrhoids may cause few problems.
[7] However, when thrombosed, hemorrhoids may be very painful.
[2][3] Nevertheless this pain typically resolves in 2 - 3 days.
[5] The swelling however may take a few weeks to disappear.
[5] A
skin tag may remain after healing.
[2]
If hemorrhoids are large and cause issues with hygiene, they may
produce irritation of the surrounding skin and thus itchiness around the
anus.
[7]
Internal
Internal hemorrhoids usually present with painless, bright red,
rectal bleeding during or following a bowel movement.
[2] The blood typically covers the stool, a condition known as
hematochezia, is on the toilet paper, or drips into the toilet bowl.
[2] The stool itself is usually normally coloured.
[2] Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus,
itchiness, and
fecal incontinence.
[8][6] Internal hemorrhoids are usually only painful if they become thrombosed or
necrotic.
[2]
Causes
The exact cause of symptomatic hemorrhoids is unknown.
[9] A number of factors are believed to play a role including: irregular bowel habits (
constipation or
diarrhea), a lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining,
ascitis, an intra-abdominal mass, or
pregnancy), genetics, an absence of valves within the hemorrhoidal veins, and aging.
[3][5] Other factors that are believed to increase the risk include
obesity, prolonged sitting,
[2] a
chronic cough and
pelvic floor dysfunction.
[4] Evidence for these associations, however, is poor.
[4]
During
pregnancy, pressure from the
fetus
on the abdomen and hormonal changes cause the hemorrhoidal vessels to
enlarge. Delivery also leads to increased intra-abdominal pressures.
[10] Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery.
[3]
Pathophysiology
Hemorrhoid cushions are a part of normal human anatomy and become a
pathological disease only when they experience abnormal changes.
[2] There are three main cushions present in the normal
anal canal.
[3] These are located classically at left lateral, right anterior, and right posterior positions.
[5] They are composed of neither
arteries nor
veins but blood vessels called
sinusoids,
connective tissue and
smooth muscle.
[4] Sinusoids do not have
muscle tissue in their walls, as veins do.
[2] This set of blood vessels is known as the
hemorrhoidal plexus.
[4]
Hemorrhoid cushions are important for
continence. They contribute to 15–20% of anal closure pressure at rest and protect the
anal sphincter muscles during the passage of stool.
[2]
When a person bears down, the intra-abdominal pressure grows, and
hemorrhoid cushions increase in size helping to maintain the anus
closed.
[5]
It is believed that hemorrhoid symptoms result when these vascular
structures slide downwards or when venous pressure is excessively
increased.
[6] Increased
anal sphincter pressure may also be involved in hemorrhoid symptoms.
[5] Two types of hemorrhoids occur: internals from the
superior hemorrhoidal plexus and externals from the inferior hemorrhoidal plexus.
[5] The
dentate line divides the two regions.
[5]
Diagnosis
Internal hemorrhoid grades
| Grade |
Diagram |
Picture |
| 1 |
 |
 |
| 2 |
 |
 |
| 3 |
 |
 |
| 4 |
 |
 |
Hemorrhoids are typically diagnosed by physical examination.
[11] A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids.
[2] A
rectal exam may be performed to detect possible rectal
tumors,
polyps, an enlarged
prostate, or
abscesses.
[2] This examination may not be possible without appropriate
sedation due to pain, although most internal hemorrhoids are not associated with pain.
[3] Visual confirmation of internal hemorrhoids may require
anoscopy, a hollow tube device with a light attached at one end.
[5] There are two types of hemorrhoids: external and internal. These are differentiated by their position with respect to the
dentate line.
[3] Some persons may concurrently have symptomatic versions of both.
[5] If pain is present the condition is more likely to be an
anal fissure or an external hemorrhoid rather than an internal hemorrhoid.
[5]
Internal
Internal hemorrhoids are those that originate above the
dentate line.
[7] They are covered by
columnar epithelium which lacks pain
receptors.
[4] They were classified in 1985 into four grades based on the degree of
prolapse.
[4][3]
- Grade I: No prolapse. Just prominent blood vessels.[11]
- Grade II: Prolapse upon bearing down but spontaneously reduce.
- Grade III: Prolapse upon bearing down and requires manual reduction.
- Grade IV: Prolapsed and cannot be manually reduced.
External
A thrombosed external hemorrhoid
External hemorrhoids are those that occur below the dentate or
pectinate line.
[7] They are covered proximately by
anoderm and distally by skin, both of which are sensitive to pain and temperature.
[4]
Differential
Many anorectal problems, including
fissures,
fistulae, abscesses,
colorectal cancer,
rectal varices and
itching have similar symptoms and may be incorrectly referred to as hemorrhoids.
[3] Rectal bleeding may also occur due to colorectal cancer,
colitis including
inflammatory bowel disease,
diverticular disease, and
angiodysplasia.
[11] If
anemia is present, other potential causes should be considered.
[5]
Other conditions that produce an anal mass include:
skin tags,
anal warts,
rectal prolapse,
polyps and enlarged anal papillae.
[5] Anorectal varices due to increased
portal hypertension (blood pressure in the
portal venous system) may present similar to hemorrhoids but are a different condition.
[5]
Prevention
A number of preventative measures are recommended including avoiding
straining while attempting to defecate, avoiding constipation and
diarrhea either by eating a high fiber diet and drinking plenty of fluid
or taking fiber supplements, and getting sufficient exercise.
[12][5] Spending less time attempting to
defecate, avoiding reading while on the toilet,
[3] as well as losing weight for overweight persons and avoiding heavy lifting are also recommended.
[13]
Management
Conservative
Conservative treatment typically consists of nutrition rich in
dietary fiber, uptake of oral fluids to maintain hydration,
non-steroidal anti-inflammatory drugs (NSAID)s,
sitz baths, and rest.
[3] Increased fiber intake has been shown to improve outcomes,
[14] and may be achieved by dietary alterations or the consumption of
fiber supplements.
[3][14] Evidence for benefits from sitz baths during any point in treatment however is lacking.
[15] If they are used they should be limited to 15 minutes at a time.
[4]
While many topical agents and suppositories are available for the
treatment of hemorrhoids, there is little evidence to support their use.
[3] Steroid containing agents should not be used for more than 14 days as they may cause thinning of the skin.
[3] Most agents include a combination of active ingredients.
[4] These may include: a barrier cream such as
petroleum jelly or
zinc oxide, an analgesic agent such as
lidocaine, and a vasoconstrictor such as
epinephrine.
[4] Flavonoids are of questionable benefit with potential side effects.
[16][4] Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery.
[17]
Procedures
A number of office based procedures may be performed. While generally safe, rare serious side effects such as
perianal sepsis may occur.
[11]
- Rubber band ligation is typically recommended as the first line treatment in those with grade 1 to 3 disease.[11] It is a procedure in which elastic bands are applied onto an internal hemorrhoid at least 1 cm above the dentate line
to cut off its blood supply. Within 5–7 days, the withered hemorrhoid
falls off. If the band is placed too close to the dentate line, intense
pain results immediately afterwards.[3] Cure rate has been found to be about 87%[3] with a complication rate of up to 3%.[11]
- Sclerotherapy involves the injection of a sclerosing agent, such as phenol,
into the hemorrhoid. This causes the vein walls to collapse and the
hemorrhoids to shrivel up. The success rate four years after treatment
is ~70%[3] which is higher than that with rubber band ligation.[11]
- A number of cauterization
methods have been shown to be effective for hemorrhoids, but are
usually only used when other methods fail. This procedure can be done
using electrocautery, infrared radiation, laser surgery,[3] or cryosurgery.[18] Infrared cauterization may be an option for grade 1 or 2 disease.[11] In those with grade 3 or 4 disease re-occurrence rates are high.[11]
Surgery
A number of surgical techniques may be used if conservative management and simple procedures fail.
[11] All surgical treatments are associated with some degree of complications including bleeding, infection,
anal strictures and
urinary retention, due to the close proximity to the rectum to the nerves that supply the bladder.
[3] There may also be a small risk of
fecal incontinence, particularly of liquid,
[19][4] with rates reported between 0% and 28%.
[20] Mucosal
ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis).
[21] This is where the anal mucosa becomes everted from the anus, similar to a very mild form of
rectal prolapse.
[21]
- Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily only in severe cases.[3] It is associated with significant post-operative pain and usually requires 2–4 weeks for recovery.[3] However, there is greater long term benefit in those with grade 3 hemorrhoids as compared to rubber band ligation.[22] It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24-72 hours.[11][7] Glyceryl trinitrate ointment post procedure, helps both with pain and healing.[23]
- Doppler-guided, transanal hemorrhoidal dearterialization
is a minimally invasive treatment using an ultrasound doppler to
accurately locate the arterial blood inflow. These arteries are then
"tied off" and the prolapsed tissue is sutured back to its normal
position. It has a slightly higher recurrence rate, but fewer
complications compared to a hemorrhoidectomy.[3]
- Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy,
is a procedure that involves the removal of much of the abnormally
enlarged hemorrhoidal tissue, followed by a repositioning of the
remaining hemorrhoidal tissue back to its normal anatomic position. It
is generally less painful and is associated with faster healing compared
to complete removal of hemorrhoids.[3] However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorroidectomy[24] and thus it is typically only recommended for grade 2 or 3 disease.[11]
Epidemiology
It is difficult to determine how common hemorrhoids are as many people with the condition do not see a healthcare provider.
[9][6]
However, it is believed that symptomatic hemorrhoids affect at least
50% of the US population at some time during their lives and around ~5%
of the population is affected at any given time.
[3] Both sexes experience approximately the same incidence of the condition
[3] with rates peaking between 45 and 65 years.
[5] They are more common in
Caucasians[25] and those of higher socioeconomic status.
[4] Long term outcomes are generally good, although some people may have recurrent symptomatic episodes.
[6] Only a small proportion of persons end up needing surgery.
[4]
History
11th century English miniature. On the right is an operation to remove hemorrhoids.
The first known mention of this affliction is from a 1700 BC Egyptian
papyrus, which advises: “… Thou shouldest give a recipe, an ointment of great protection;
Acacia
leaves, ground, titurated and cooked together. Smear a strip of fine
linen there -with and place in the anus, that he recovers immediately."
[26] In 460 BC, the
Hippocratic corpus
discusses a treatment similar to modern rubber band ligation: “And
hemorrhoids in like manner you may treat by transfixing them with a
needle and tying them with very thick and woolen thread, for
application, and do not forment until they drop off, and always leave
one behind; and when the patient recovers, let him be put on a course of
Hellebore.”
[26] Descriptions of hemorrhoids also occur in the
Bible.
[27][5]
Celsus (25 BC – AD 14) described ligation and excision procedures, and discussed the possible complications.
[28] Galen advocated severing the connection of the arteries to veins, claiming that it offered reduced pain and the spread of gangrene.
[28] The
Susruta Samhita, (4th – 5th century AD), similar to the words of Hippocrates, but emphasizes wound cleanliness.
[26] In the 13th century, European surgeons such as
Lanfranc of Milan,
Guy de Chauliac,
Henri de Mondeville and John of Ardene made great progress and development of the surgical techniques.
[28]
The first use of the word "hemorrhoid" in English occurs in 1398, derived from the
Old French "emorroides", from
Latin "hæmorrhoida -ae",
[29] in turn from the
Greek "αἱμορροΐς" (
haimorrhois), "liable to discharge blood", from "αἷμα" (
haima), "blood"
[30] + "ῥόος" (
rhoos), "stream, flow, current",
[31] itself from "ῥέω" (
rheo), "to flow, to stream".
[32]
Notable cases
Hall-of-Fame baseball player
George Brett was removed from a game in the
1980 World Series
due to hemorrhoid pain. After undergoing minor surgery, Brett returned
to play in the next game, quipping "...my problems are all behind me."
[33] Brett underwent further hemorrhoid surgery the following spring.
[34] Conservative political commentator
Glenn Beck underwent surgery for hemorrhoids, subsequently describing his unpleasant experience in a widely viewed 2008
YouTube video.
[35]
References
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- ^ a b c d e f g h i j k l m n o Schubert, MC; Sridhar, S; Schade, RR; Wexner, SD (July 2009). "What every gastroenterologist needs to know about common anorectal disorders". World J Gastroenterol 15 (26): 3201–9. doi:10.3748/wjg.15.3201. ISSN 1007-9327. PMC 2710774. PMID 19598294.
- ^ a b c d e f g h i j k l m n o p q r s t u v w x y Lorenzo-Rivero, S (August 2009). "Hemorrhoids: diagnosis and current management". Am Surg 75 (8): 635–42. PMID 19725283.
- ^ a b c d e f g h i j k l m n o Beck, David (2011). The ASCRS textbook of colon and rectal surgery (2nd ed. ed.). New York: Springer. pp. 174-177. ISBN 9781441915818.
- ^ a b c d e f g h i j k l m n o p q r s Kaidar-Person, O; Person, B; Wexner, SD (2007 Jan). "Hemorrhoidal disease: A comprehensive review". Journal of the American College of Surgeons 204 (1): 102-17. PMID 17189119.
- ^ a b c d e Davies, RJ (2006 Jun). "Haemorrhoids.". Clinical evidence (15): 711-24. PMID 16973032.
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- ^ Azimuddin, edited by Indru Khubchandani, Nina Paonessa, Khawaja (2009). Surgical treatment of hemorrhoids (2nd ed. ed.). New York: Springer. p. 21. ISBN 978-1-84800-313-2.
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- ^ Quijano,
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- ^ Pescatori,
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- ^ hæmorrhoida, Charlton T. Lewis, Charles Short, A Latin Dictionary, on Perseus Digital Library
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- ^ Dick Kaegel (March 5, 2009). "Memories fill Kauffman Stadium". Major League Baseball.
- ^ "Brett in Hospital for Surgery". The New York Times. Associated Press. March 1, 1981.
- ^ "Glenn Beck: Put the 'Care' Back in Health Care". ABC Good Morning America. Jan. 8, 2008. Retrieved 17 September 2012.
