Hemorrhoids

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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.

Hemorrhoids were first discovered by ancient Egyptians more than 3,700 years ago.

Hemorrhoids can be classified according to their location as external or internal hemorrhoids. Furthermore, internal hemorrhoids can be graded according to severity into 4 grades.

Hemorrhoids develop due to a combination of genetic predisposition (weak rectal veins) and certain diet and defecation habits.

Hemorrhoids may be caused by factors that increase the pressure in the rectal veins such as chronic cough, chronic constipation, and straining.

Hemorrhoids should be differentiated from other diseases that cause anal discomfort and pain with defecation such as rectal cancer, anal fissure, anal abscess, and anal fistula.

In the USA, the prevalence of hemorrhoids is about 4.4%. Only about 500,000 patients in the U.S. are medically treated for massive hemorrhage, with 10 to 20% requiring surgery.^[1]

Common risk factors in the development of hemorrhoids are excessive straining, sitting or standing for long periods of time, pregnancy, and chronic constipation.

According to the USPSTF, screening for hemorrhoids is not recommended.

If left untreated, hemorrhoids may lead to 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.

Symptoms of hemorrhoids include pain with defecation, hematochezia, and anal discharge.

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.

There are no specific diagnostic lab findings associated with hemorrhoids. However, complete blood count may show anemia in the case of chronic bleeding.

There are no X-ray, MRI or ultrasound findings associated with hemorrhoids.

There are no other diagnostic imaging studies of significance for hemorrhoids.

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.

There is no medical treatment for hemorrhoids. Medical therapy aims to provide symptomatic relief from constipation. Local treatments such as warm sitz baths, cold compress, and topical analgesic (such as nupercainal) can provide temporary relief.

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 of hemorrhoids may include drinking excessive fluids, regular exercise, practicing better posture, and reduction of bowel movement straining and time. Eating a high-fiber diet can make stools softer and easier to pass, reducing the pressure on hemorrhoids caused by straining.

The secondary preventive measures for hemorrhoids are similar to primary preventive measures.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Hemorrhoids were first discovered by ancient Egyptians more than 3,700 years ago.

• Hemorrhoids were known 3,700 years ago by ancient Egyptians. A recipe for an ointment made of ground acacia leaves was described in an ancient Egyptian manuscript.
• The ancient Greek medical textbook “Hippocratic Corpus” described a maneuver that is similar to rubber band ligation as we know it today.
• Roman encyclopedist Aulus Cornelius Celsus described band ligation and discussed possible complications. The Roman surgeon Galen suggested severing the connection between arteries and veins in an attempt to relieve the pain and the spread of infection.
• During the sixth century, hemorrhoids were known as Saint Fiacre’s curse after a saint who developed them after working in his farm.
• In 1398, the word “hemorrhoids” was first used in English after the French word “emorroides,” which developed from the Latin word “hæmorrhoida”. “Hæmorrhoida” means liable to bleeding.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Hemorrhoids can be classified according to their location as external or internal hemorrhoids. Furthermore, internal hemorrhoids can be graded according to severity into 4 grades.

Hemorrhoids can be classified according to their location as external or internal hemorrhoids.^[1]

• External hemorrhoids occur below the dentate line at the external anal orifice.
• External hemorrhoids are often painful and can be accompanied by a bluish-purple swelling near the anal orifice.
• Itching, although often thought to be a symptom of external hemorrhoids, is more commonly due to skin irritation due to difficulty in cleaning fecal matter after defecation.
• External hemorrhoids are prone to thrombosis; if a vein ruptures and a blood clot develops, the hemorrhoids become thrombosed.^[2] A thrombosed external hemorrhoid can lead to bright red bleeding.
• External hemorrhoids may leave a painless skin tag that causes difficulty in maintaining anal hygiene.

• Internal hemorrhoids occur above the dentate line.
• As this area lacks pain receptors, internal hemorrhoids are usually not painful and most people are not aware that they have them.
• Internal hemorrhoids, however, may bleed when irritated. Bleeding is painless and seen as blood covering the outer part of solid stool.
• Itching can occur due to deposition of mucus on skin around the anal orifice.
• Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids.
• Hemorrhoid may be strangulated when it is trapped by the anal sphincter.

Furthermore, internal hemorrhoids can be graded according to severity into 4 grades. The most common grading system was developed by Banov:^[3]

• Grade I: The hemorrhoids prolapse into the anal canal.
• Grade II: The hemorrhoids prolapse upon defecation but spontaneously reduce.
• Grade III: The hemorrhoids prolapse upon defecation, but must be manually reduced.
• Grade IV: The hemorrhoids are prolapsed and cannot be manually reduced.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Hemorrhoids develop due to a combination of genetic predisposition (weak rectal veins) and certain diet and defecation habits.

• Hemorrhoids can be internal and external.

• Internal hemorrhoids are located above the dentate line and they occur due to dilatation of the superior hemorrhoidal plexus.^[1]

• The connective tissue over the superior hemorrhoidal plexus is innervated via visceral nerves and thus it is pain insensitive.

• External hemorrhoids are located below the dentate line and occur due to dilatation of the inferior hemorrhoidal plexus.^[2]

• The first step in the pathogenesis of either type of hemorrhoids is weakening of the surrounding connective tissue, musculature and vein wall. All the risk factors (old age, pregnancy, straining during defecation, portal hypertension, etc) lead to aggravating this weakness or add more pressure from within the vein. ^[3][4]

• Increased tone of the internal anal sphincter causing the feces to press the hemorrhoid against the muscle and thus decreasing venous return and aggravating the symptoms.^[5]

• The arteriovenous anastomosis may play a role in the development of hemorrhoids. This is supported by the fact that some hemorrhoids improve after ligating the connecting arteries.^[6]

• The redundant bulging mucosa is easily injured causing bleeding. The blood is usually bright red reflecting high oxygen content due to the proximity of AV anastomosis.

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• External hemorrhoids appear on inspection of the anal verge as skin tags or strangulated or free prolapsed veins.
• Internal hemorrhoids appear as bluish bulgings of the veins in the mucosa.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Hemorrhoids may be caused by factors that increase the pressure in the rectal veins such as chronic cough, chronic constipation, and straining.

Hemorrhoids may be caused by factors that increase the pressure in the rectal veins including the following:^[1]

• Advanced age
• Chronic constipation
• Chronic cough
• Cirrhosis
• Heavy lifting
• Low dietary fiber
• Sedentary lifestyle
• Straining
• Ascites

• Advanced age
• Anal intercourse
• Ascites
• Chronic constipation
• Chronic cough
• Cirrhosis
• Diarrhea
• Heavy lifting
• Increase intra-abdominal pressure
• Low dietary fiber
• Obesity
• Pelvic tumors
• Portal hypertension
• Pregnancy
• Prolonged sitting
• Sedentary lifestyle
• Straining with prostatism
• Straining

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Hemorrhoids should be differentiated from other diseases that cause anal discomfort and pain with defecation such as rectal cancer, anal fissure, anal abscess, and anal fistula.

Hemorrhoids should be differentiated from other diseases that cause anal discomfort and pain with defecation such as anal fissure, rectal prolapse and perianal abscess.

Disease	History	Physical exam findings	Sample image
Hemorrhoids	External hemorrhoids External hemorrhoids are painful as the skin below the punctate line is sensitive to pain.[1] Blood clots may form in external hemorrhoids. Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus. When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch. Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse. Internal hemorrhoids The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement. Internal hemorrhoids that are not prolapsed are usually not painful. Prolapsed hemorrhoids often cause pain, discomfort, and anal itching	Skin examination Inspection of the anal verge may show scratch marks and skin tags. Inspection also may reveal external hemorrhoids or prolapsed internal hemorrhoids. Digital rectal examination Digital rectal examination reveals the size and location of hemorrhoids. Thrombosed hemorrhoids are tender to palpation. Internal hemorrhoids are not palpable by digital rectal examination and the use of anoscope is mandatory.
Anal fissure	Anal fissure usually presents with tearing pain with every bowel movement.[1] Pain usually lasts for minutes to hours after every bowel movement. Patient is typically afraid of going to the bathroom to avoid the pain, which leads to a viscious cycle. The fissure worsens the constipation and the constipation (hard stool) aggravates the fissure. About two-thirds of the patients present with bright red blood streaks on toilet papers or on the surface of stools. May be accompanied by pruritis and discharge.	Most fissures occur in the posterior midline of the anal canal.[2] Skin tags in the perianal area may accompany chronic anal fissures.
Rectal prolapse	Rectal prolapse most commonly occurs in multiparous females over 40 years old.[3] Appears as a progressive mass protrusion from the anus. The protrusion first appears with straining and defecation, then progresses to the degree when it is no longer replaced back. It presents with abdominal discomfort and incomplete defecation. Fecal incontinence and anal discharge. Pain is not usually present.	Mass protruding from the anus.[4] Concentric mucosal rings are characteristic of rectal prolapse.
Perianal abscess	Perianal abscess presents with severe, continuous, dull, aching pain in the perianal area.[5] Pain is exacerbated with bowel movements, but is not exclusive to it. Constipation due to fear of bowel movements. Fever, headache, and chills may accompany the pain. If the abscess starts to drain, discharge of purulent or bloody fluid may be noticed.	Flatulent, erythematous, and tender area of skin overlying the abscess. If abscess is deep, tenderness is elicited with digital rectal examination.
Anal cancer	Rectal bleeding is the most common presentation.[6] Mass sensation in the anus. Mucoid discharge may occur. Patient may give a history of anal condyloma (especially homosexual men).[7] Fecal incontinence.	On digital rectal examination, solid hemorrhagic mass that is firmly fixed to the surrounding structures is noted. Femoral and inguinal lymph nodes may show lymphadenopathy secondary to spread of cancer.
Condylomata acuminata	Patient may give a history of unprotected anal sex with an infected partner. Having multiple sexual partners is a risk factor and should be investigated.[8] Condyloma acuminata presents with painless warts that vary in size, shape, and color. Pruritis and discharge may accompany the warts.	Anal condyloma acuminata may be accompanied by cervical, vaginal, or even ororpharyngeal warts, so the patient should be examined thoroughly.[9]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

In the USA, the prevalence is about 4,400 per 100,000 individuals. Only about 500,000 patients in the U.S. are medically treated for massive hemorrhage, with 10 to 20% requiring surgery.^[1]

• In the USA, the prevalence is about 4,400 per 100,000 individuals.^[1]
• It is the fourth most common diagnosis related to the gastrointestinal system.^[1]
• It is estimated that approximately one half of all Americans have had this condition by the age of 50, and that 50% to 85% of the world’s population will be affected by hemorrhoids at some point in their life. However, only a small number seek medical treatment.
• Hemorrhoids account for four million annual ambulatory care visits in the USA.^[1]
• Annually, only about 500,000 in the U.S. are medically treated for massive hemorrhage, with 10 to 20% requiring surgery.^[1]

Hemorrhoids are most prevalent in people between 45-65 years old.^[1]

Both males and females are affected equally by hemorrhoids.^[1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Common risk factors in the development of hemorrhoids are excessive straining, sitting or standing for long periods of time, pregnancy, and chronic constipation.

Risk factors of hemorrhoids include:

• Aging
• Anal intercourse
• Chronic constipation^[1]
  • Straining during defecation^[2]
  • Incomplete emptying of bowel during defecation^[2]
  • Hard stools^[2]
• Cirrhosis^[3]
  • Hemorrhoids may be confused with Anorectal Varices
  • Hemorrhoids are more commonly seen in Cirrhosis with Portal Hypertension than Cirrhosis without Portal Hypertension
• Diarrhea^[4]
  • History of Colitis^[5]
  • History of Intestinal Malabsorption^[5]
  • Patient had previously undergone Intestinal Bypass^[5]
• High-fat, low-fiber diet
• Obesity
• Pregnancy^[6]
  • Previous history of hemorrhoidal disease, anal fissures and constipation in pregnant female
  • Straining during delivery for more than 20 minutes
  • Newborn weighs more than 3800g at birth
  • Hemorrhoids are most common in the third trimester of the pregnancy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

There is insufficient evidence for screening patients for hemorrhoids.

There is insufficient evidence for screening patients for hemorrhoids.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

If left untreated, hemorrhoids may lead to 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.

• If left untreated, hemorrhoids may lead to strangulation, thrombosis, or infection.
• The main reasons for a delay in seeking medical advice are as follows:

• Myths about the surgical treatment
• Postoperative pain
• Fear of incontinence after surgery^[1]

• Strangulation: The prolapsed hemorrhoids can be trapped outside the anal canal if the anal sphincter goes into spasm. This can lead to thrombosis of the hemorrhoids or cutting of the blood supply to the hemorrhoids
• Secondary infection and abscess formation
• Hemorrhoid thrombosis

• Anemia due to chronic bleeding
• Fecal incontinence

• Anal stenosis
• Wound dehisence
• Wound sepsis
• Fistula formation

• The prognosis is excellent.
• Most cases respond well to non surgical procedures such as rubber band ligation (recurrence rate is 30-50% after 5 years); however, the recurrence rate is much less with surgical hemorrhoidectomy (2-5% after 5 years).^[2][3]
• The difference in recurrence rate is more pronounced with grade III hemorrhoids.

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