Hemorrhoid
Hemorrhoids, also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term hemorrhoid is often used to refer to the disease. The signs and symptoms of hemorrhoids depend on the type present. Internal hemorrhoids often result in painless, bright red rectal bleeding when defecating. External hemorrhoids often result in pain and swelling in the area of the anus. If bleeding occurs, it is usually darker. Symptoms frequently get better after a few days. A skin tag may remain after the healing of an external hemorrhoid.
While the exact cause of hemorrhoids remains unknown, a number of factors that increase pressure in the abdomen are believed to be involved. This may include constipation, diarrhea, and sitting on the toilet for long periods. Hemorrhoids are also more common during pregnancy. Diagnosis is made by looking at the area. Many people incorrectly refer to any symptom occurring around the anal area as hemorrhoids, and serious causes of the symptoms should be ruled out. Colonoscopy or sigmoidoscopy is reasonable to confirm the diagnosis and rule out more serious causes.
Often, no specific treatment is needed and hemorrhoids that do not cause symptoms do not require treatment. Initial measures consist of increasing fiber intake, drinking fluids to maintain hydration, NSAIDs to help with pain, and rest. Medicated creams may be applied to the area, but their effectiveness is poorly supported by evidence. A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management. Hemorrhoidal artery embolization is a safe and effective minimally invasive procedure that can be performed and is typically better tolerated than traditional therapies. Surgery is reserved for those who fail to improve following these measures.
Approximately 50% to 66% of people have problems with hemorrhoids at some point in their lives. Males and females are both affected with about equal frequency. Hemorrhoids affect people most often between 45 and 65 years of age, and they are more common among the wealthy, although this may reflect differences in healthcare access rather than true prevalence. Outcomes are usually good.
The first known mention of the disease is from a 1700 BC Egyptian papyrus.
Signs and symptoms
In about 40% of people with pathological hemorrhoids, there are no significant symptoms. Internal and external hemorrhoids may present differently; however, many people may have a combination of the two. Bleeding enough to cause anemia is rare, and life-threatening bleeding is even more uncommon. Many people feel embarrassed when facing the problem and often seek medical care only when the case is advanced.External
If not thrombosed, external hemorrhoids may cause few problems. However, when thrombosed, hemorrhoids may be very painful. Nevertheless, this pain typically resolves in two to three days. The swelling may, however, take a few weeks to disappear. A skin tag may remain after healing. If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus.Internal
Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement. The blood typically covers the stool, is on the toilet paper, or drips into the toilet bowl. The stool itself is usually normally colored. Blood mixed in with the stool is usually due to another cause of bleeding in the gut. Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus, itchiness, and fecal incontinence. Internal hemorrhoids are usually painful only if they become thrombosed or necrotic.Causes
The exact cause of symptomatic hemorrhoids is unknown. A number of factors are believed to play a role, including irregular bowel habits, lack of exercise, nutritional factors, increased intra-abdominal pressure, genetics, an absence of valves within the hemorrhoidal veins, and aging. Other factors believed to increase risk include obesity, a chronic cough, and pelvic floor dysfunction. Squatting while defecating may also increase the risk of severe hemorrhoids. Evidence for these associations, however, is poor. Being a receptive partner in anal intercourse has been listed as a cause.During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures. Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery. A personal history of hemorrhoids or anal fissures, constipation, prolonged straining during delivery, and delivering a larger baby are risk factors for hemorrhoids during pregnancy and in the post-partum period.
Pathophysiology
Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes. There are three main cushions present in the normal anal canal. These are located classically at left lateral, right anterior, and right posterior positions. They are composed of neither arteries nor veins, but blood vessels called sinusoids, connective tissue, and smooth muscle. Sinusoids do not have muscle tissue in their walls, as veins do. This set of blood vessels is known as the hemorrhoidal plexus.Hemorrhoid cushions are important for continence. They contribute to 15–20% of anal closure pressure at rest and protect the internal and external anal sphincter muscles during the passage of stool. When a person bears down, the intra-abdominal pressure grows, and hemorrhoid cushions increase in size, helping maintain anal closure. Hemorrhoid symptoms are believed to result when these vascular structures slide downwards or when venous pressure is excessively increased. Increased internal and external anal sphincter pressure may also be involved in hemorrhoid symptoms. Two types of hemorrhoids occur: internals from the superior hemorrhoidal plexus and externals from the inferior hemorrhoidal plexus. The pectinate line divides the two regions, and is also used to divide internal from external hemorrhoids.
Diagnosis
Hemorrhoids are typically diagnosed by physical examination. A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids. Visual confirmation of internal hemorrhoids, on the other hand, may require anoscopy, insertion of a hollow tube device with a light attached at one end. A digital rectal exam can also be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses. If pain is present, the condition is more likely to be an anal fissure or external hemorrhoid rather than internal hemorrhoid.Internal
Internal hemorrhoids originate above the pectinate line. They are covered by columnar epithelium, which lacks pain receptors. They were classified in 1985 into four grades based on the degree of prolapse:- Grade I: No prolapse, just prominent blood vessels
- Grade II: Prolapse upon bearing down, but spontaneous reduction
- Grade III: Prolapse upon bearing down requiring manual reduction
- Grade IV: Prolapse with inability to be manually reduced.
External
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. Rectal bleeding may also occur owing to colorectal cancer, colitis including inflammatory bowel disease, diverticular disease, and angiodysplasia. If anemia is present, other potential causes should be considered. Rectal bleeding without bowel movements is unlikely to be due to hemorrhoids.Other conditions that produce an anal mass include skin tags, anal warts, rectal prolapse, polyps, and enlarged anal papillae. Anorectal varices due to portal hypertension may present similar to hemorrhoids but are a different condition. Portal hypertension does not increase the risk of hemorrhoids.
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 by taking fiber supplements and getting sufficient exercise. Spending less time attempting to defecate, avoiding reading while on the toilet, and losing weight for overweight persons and avoiding heavy lifting are also recommended.Management
Conservative
Conservative treatment typically consists of foods rich in dietary fiber, intake of oral fluids to maintain hydration, nonsteroidal anti-inflammatory drugs, sitz baths, and rest. Increased fiber intake has been shown to improve outcomes and may be achieved by dietary alterations or the consumption of fiber supplements. Evidence for benefits from sitz baths during any point in treatment, however, is lacking. If they are used, they should be limited to 15 minutes at a time. Decreasing time spent on the toilet and not straining is also recommended.While many topical agents and suppositories are available for the treatment of hemorrhoids, little evidence supports their use. As such, they are not recommended by the American Society of Colon and Rectal Surgeons. Steroid-containing agents should not be used for more than 14 days, as they may cause thinning of the skin. Most agents include a combination of active ingredients. 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. Some contain Balsam of Peru to which certain people may be allergic.
Flavonoids are of questionable benefit, with potential side effects. Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery. Evidence does not support the use of traditional Chinese herbal treatment.
The use of phlebotonics has been investigated in the treatment of low-grade hemorrhoids with a Cochrane review showing improvement in overall symptoms, including bleeding and itching. However there were no improvements in pain. The authors noted that more research was needed on the role of phlebotonics in the management of hemorrhoids.