Hemorrhoids overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Hemorrhoids are varicosities or swelling and inflammation of veins in the rectum and anus. The rectum is the last part of the large intestine leading to the anus. The anus is the opening at the end of the digestive tract where bowel contents leave the body. External hemorrhoids are located under the skin around the anus. Internal hemorrhoids develop in the lower rectum. Internal hemorrhoids may protrude, or prolapse, through the anus. Most prolapsed hemorrhoids shrink back inside the rectum on their own. Severely prolapsed hemorrhoids may protrude permanently and require treatment.
Historical Perspective
Hemorrhoids were first discovered by ancient Egyptians more than 3700 years ago.
Classification
Hemorrhoids can be classified according to their site into external and internal hemorrhoids. Furthermore, internal hemorrhoids can be graded according to severity into 4 grades.
Pathophysiology
Hemorrhoids are developed due to combination of genetic predisposition (weak rectal veins) and following certain diet and defecation habits.
Causes
Hemorrhoids may be caused by caused by factors that increase the pressure in the rectal veins such as chronic cough, chronic constipation and straining.
Differentiating Hemorrhoids from other Diseases
Hemorrhoids should be differentiated from other diseases causing anal discomfort and pain with defaecation such as rectal cancer, anal fissure, anal abscess, anal fistula.
Epidemiology and Demographics
In the USA, the prevalence is about 4.4% while only about 500,000 patients in the U.S. are medically treated for massive hemorrhage, with 10 to 20% of them requiring surgeries. [1]
Risk Factors
Common risk factors in the development of hemorrhoids are excessive straining, sitting or standing for long periods of time, pregnancy, and Chronic constipation.
Screening
According to the USPSTF, screening for hemorrhoids is not recommended.
Natural History, Complications, and Prognosis
If left untreated, hemorrhoids may progress to develop strangulation, anemia or fecal incontinence. Common complications of hemorrhoids include secondary infection, thrombosis or strangulation. Prognosis is generally excellent and most cases respond to non surgical treatment. However, surgery gives the best prognosis with the least recurrence rate.
Diagnosis
History and Symptoms
Symptoms of hemorrhoids include pain with defecation, haematochezia, and anal discharge.
Physical Examination
Patients with acute prolapsed or thrombosed hemorrhoids usually appear ill and in pain. Physical examination of patients with hemorrhoids is usually remarkable for protruding mass from the anus or palpable mass on digital rectal exam.
Laboratory Findings
There are no specific diagnostic lab findings associated with hemorrhoids. However, complete blood count may show anemia in case of chronic bleeding.
Imaging Findings
There are no x ray, MRI or ultrasound findings associated with hemorrhoids.
Other Imaging Finidings
There are no other diagnostic imaging studies of significance for hemorrhoids.
Other Diagnostic Studies
Anoscopy is mandatory to visualize internal hemorrhoids as they are not visible on inspection of the anal verge or palapable on performing digital rectal exam.
Treatment
Medical Therapy
There is no medical treatment for hemorrhoids; the mainstay of therapy is local treatments such as warm sitz baths, using a bidet, extendable showerhead, cold compress, or topical analgesic (such as Nupercainal), can provide temporary relief.
Surgery
Surgery is not the first-line treatment option for patients with hemorrhoids. Surgical intervention is usually reserved for patients with either complicated or large hemorrhoids (beyond grade III)
Primary Prevention
Eating a high-fiber diet can make stools softer and easier to pass, reducing the pressure on hemorrhoids caused by straining.