1396
Dilated sinusoids classified as internal, external or mixed.
Hemorrhoids are vascular and connective tissue structures that line the anal canal, and are present in all individuals, although the term is commonly used to refer to a diseased state: hemorrhoid disease.
Hemorrhoids are part of the normal anal-rectum and filled with blood during defecation, facilitating continence and protecting the anal sphincter from injury during defecation.
This tissue pathology affects about 10 million Americans.
Hemorrhoid disease is the fourth leading outpatient gastrointestinal diagnosis accounting for 4 million annual ambulatory care visits and annual healthcare expenditures of $1.3 billion.
Internal hemorrhoidal disease presents with painless bleeding, and/or prolapse of internal hemorrhoid tissue prompted by a bowel movement to other Valsalva inducing activities, such as coughing or straining.
Typical hemorrhoidal bleeding results in blood adherent to the outside of formed stool or dripping into the toilet during defecation.
Hemorrhoidal disease may impair quality of life due to bleeding, pain, anal irritation, and tissue prolapse.
Prolapsed internal hemorrhoids can deposit mucus secretions on the perianal skin, causing wetness and itching.
May develop inside the anus and protrude outside or appear outside the anus and be covered by skin.
About 95% of patients with internal hemorrhoid disease report anal pain and almost 90% have anal discomfort, 61% with perianal itching and 60% with swelling and almost 60% with rectal bleeding.
Hemorrhoids are classified as internal, external, or mixed.
Internal hemorrhoids originate above the dentate line, the boundary between the upper and lower anal canal, and may cause rectal bleeding, discomfort, and tissue prolapse from the anal canal.
Hemorrhoids are categorized according to the location in the anal canal relative to the dentate line, which is approximately 3-4 cm cephalad to the anal opening.
Internal hemorrhoid prolapse is classified as grade I which is into the anal canal, grade II is beyond the anus with spontaneous reduction, and grade III requiring manual reduction, and grade IV is not reducible.
The internal hemorrhoid plexus is responsible for approximately 15% of resting anal tone, aiding anal sphincter function to prevent fecal incontinence.
With internal hemorrhoid disease, the anchoring muscular support of the hemorrhoid loses the integrity leading to encouragement and abnormal dilatation of the internal hemorrhoidal venous plexus, resulting in bleeding.
Loss of structural support results in downward displacement or prolapse of internal hemorrhoid tissue into or out of the anal canal.
External hemorrhoids are located below the dentate line and are covered with a squamous epithelium innervated by rami of the sacral spinal nerves S2, S3, and S4.
In patients with external hemorrhoid disease, veins beneath the skin dilate, causing hemorrhoid swelling: thrombosis of these veins causes acute pain.
External hemorrhoids are below the dentate line and covered by cutaneous tissue, whereas internal hemorrhoids are above the dentate line and covered by mucosa of the anal canal.
External hemorrhoids, arise below the dentate line and caused rectal pain when engorged or thrombosed.
Patients with with thrombosed external hemorrhoid have severe anal pain and bluish purple colored perianal mass easily seen on examination.
After resolution an external thrombosed external hemorrhoid can leave a skin tag that irritates and may impede anal hygiene.
External hemorrhoids are located at the external anal orifice, and may be irregularly shaped, difficult to clean, can lead to pruritus from prolonged exposure of perianal skin to fecal material.
Thrombosed external hemorrhoids most common between ages 20-60 years of age.
Thrombosed external hemorrhoids more common in males.
Rarely cause long-term health problems.
Symptoms include blood on toilet tissue or in the toilet, pain, itching, irritation, associated with protruding swollen blood vessels, with a painful hard lump near the anus.
Associated with increased venous pressure on the lower body including: straining during a bowel movement, sitting on the toilet for long periods, constipation, diarrhea, being overweight, pregnancy, and age.
Initial treatment:
Involves increasing intake of dietary fiber and water and avoiding straining during defecation.
Simple treatments include: warm baths, and topical medication measures.
Modifying hemorrhoidal risk factors, such as straining, can improve symptoms and reduce need for further treatment.
Hemorrhoidectomy may be required in severe cases.
Excisional hemorrhoidectomy for disease unresponsive to office-based therapy achieves low recurrence scores of 2 to 10 percent with a recovery time of 9 to 14 days.
Treatments include: sclerotherapy, rubber band ligation, infrared photo-coagulation, stapled hemorrhoidectomy, and excisional hemorrhoidectomy.
Phlebotonics such as flavonoids are thought to improve venous tone, reduce bleeding, rectal pain, and swelling, although symptom recurrence reaches 80% within 3 to 6 months after treatment is stopped.
Rubber band ligation associated with 89% patient satisfaction at 3 years.
Rubber band ligation is the first line in office treatment for internal hemorrhoid disease.
Sclerotherapy induces fibrosis with a sclerosis agent is efficacious in the short term among 70 to 85% of patients, but longtime remission occurs and only 1/3 of patients.
Sclerotherapy is less effective compared to rubber band ligation for bleeding and prolapse, but may have less post procedural pain.
Infrared coagulation uses heat to coagulate hemorrhoid tissue, yields 70 to 80% success in reducing bleeding and prolapse.
Symptoms related to hemorrhoids are very common in the Western hemisphere and other industrialized societies.
It represents one of the most common medical and surgical disease processes encountered in the United States, resulting in more than 2.2-million outpatient evaluations per year.
Diagnosis is almost always a clinical one.
Medical history to identify symptoms suggestive of hemorrhoidal disease and risk factors such as constipation, pregnancy, cirrhosis-portal hypertension, diarrhea.
The cardinal signs of internal hemorrhoids are painless bleeding with bowel movements with intermittent protrusion.
Focus should be on the extent, severity, and duration of symptoms such as bleeding and prolapse, issues of perineal hygiene, and presence or absence of pain. review of fiber intake and bowel habits, including frequency, consistency, and ease of evacuation.
Sharp, burning pain after a bowel movement typically indicates an anal fissure.
A careful assessment of fecal incontinence symptoms should be made.
Physical examination includes visual inspection of the anus, as well as digital rectal examination to evaluate for other anal pathology and sphincter integrity.
On physical exam, external hemorrhoids can be visualized that the anal orifice.
Chronically prolapsed internal hemorrhoids, appear as flesh mucosal tissue protruding through the anal canal, sometimes causing excoriation and deposits of fecal material and mucus on the perianal skin.
Evaluation of the patient while straining assists in the diagnosis of hemorrhoidal prolapse, as well as exclude full-thickness rectal prolapse.
An anoscopic examination should be performed to assess the anatomy.
Internal hemorrhoids, located above the dentate line, can be assigned a grade which may help to guide therapy.
Internal hemorrhoids are classified on the extent of prolapse from the anus: grade I indicates prolapse into the anal canal; grade II, prolapse during straining, but retract spontaneously; grade III, prolapse out of the anal canal and require manual reduction; and grade IV prolapse out of the anus, cannot be manually to their proper position.
Laboratory evaluation is not typically required for diagnostic purposes.
With rectal bleeding evaluation includes:
Complete endoscopic evaluation of the colon is indicated in select patients with symptomatic hemorrhoids and rectal bleeding.
Although hemorrhoidal disease is the most common reason for hematochezia, other disease processes, such as colorectal cancer, IBD, other colitides, diverticular disease, and angiodysplasia, can also precipitate bleeding.
Rectal bleeding attributed to hemorrhoids represents the most common missed opportunity to establish a cancer diagnosis.
The goals of treatment-alleviate patient symptoms by decreasing the size or vascularity of the hemorrhoidal tissue and to increase the fixation of the hemorrhoidal tissue to the rectal wall to minimize prolapse.
Medical treatment includes dietary modification consisting of adequate fluid and fiber intake and counseling regarding defecation habits typically form the primary first-line therapy for patients with symptomatic hemorrhoid disease.
Constipation, straining, prolonged sitting, and frequent bowel movements can play a significant role in patients with symptomatic hemorrhoids.
By increasing fiber and fluid intake improvement in symptoms of mild-to-moderate prolapse and bleeding are observed.
Fiber had a beneficial effect in the treatment of symptomatic hemorrhoids.
Fiber use is associated with a reduction in bleeding, whereas symptoms such as prolapse, pain, and itching are not affected.
Fiber intake of 20 to 30 g of oral fiber and 5 to 6 glasses of water daily help pass stool regularly and with mineral or no straining.
Sitz baths in involve sitting in warm water for 10 to 20 minutes and can alleviate discomfort from hemorrhoid disease, but does not have evidence to reduce hemorrhoid associated pain.
Straining and prolonged time on the commode, are associated with higher rates of symptomatic hemorrhoids.
Phlebotonics are used to treat both hemorrhoidal disease aimed at strengthening of blood vessel walls, increasing venous tone and lymphatic drainage, and normalizing capillary permeability.
In a Cochrane review, phlebotonics demonstrated a statistically significant beneficial effect for pruritus, bleeding, discharge and leakage and overall symptom improvement.
Phlebotonics do not show a statistically significant effect when compared with a control intervention for pain.
Flavonoids (diosmin, micronized purified flavonoid fraction, and rutosides) have a beneficial effect on bleeding, pruritus, and recurrence.
Topical application of ointments containing anesthetics, steroids, emollients, and/or antiseptics are used commonly, but there is no evidence regarding their long-term use.
Most patients with internal hemorrhoidal disease who fail medical treatment can be effectively treated with banding, sclerotherapy, and infrared coagulation.
Hemorrhoid banding is the most effective option, the most popular of which is rubber band ligation (RBL), which has been shown to be superior to sclerotherapy and infrared coagulation.
All treatment procedures have a variable recurrence rate and may require repeated applications.
Ligation of the hemorrhoidal tissue is well tolerated, resulting in ischemia and necrosis of the prolapsed mucosa.
Scar fixation to the rectal wall, occurs following hemorrhoidal ligation.
The ligature is performed above the dentate line, where pain sensitivity is absent.
Rubber band ligation study of 750 consecutive patients with grade II and III hemorrhoids reported a cure rate of 93% and a recurrence rate of 11% after 2 years, which was not influenced by the grade of hemorrhoid.
A Cochrane review evaluated the efficacy of rubber band ligation with respect to grade of hemorrhoids and found that excisional hemorrhoidectomy was superior for grade III hemorrhoids.
Sclerosing agents have been described for treating grade I to III internal hemorrhoids, with a mechanism of action is fibrosis of the submucosa with subsequent fixation of the hemorrhoidal tissue.
Complications of rubber band ligation ranges from 3 to 23% and includes rectal pain, and bleeding.
Injection is performed into the submucosa at the apex of a hemorrhoidal bundle, and may also result in mucosal ulceration or necrosis and rare septic complications.
Transient bacteremia has been reported in 8% of individuals after sclerotherapy, and antibiotic prophylaxis should be considered for individuals at risk.
Limited data on the efficacy of sclerotherapy: report of only 20% success at 1 year in the treatment of grade III hemorrhoids. with 88% of patients treated successfully with grade I hemorrhoids: control of symptoms in 81% of patients at 6 months after IRC, whereas 28% of patients required a repeat procedure.
Infrared coagulation involves the direct application of infrared waves resulting in protein necrosis within the hemorrhoid.
Infrared coagulation is most commonly used for grade I and II hemorrhoids
It reportedly has high rates of recurrence, especially with grade III and IV hemorrhoids.
Recent randomized studies have demonstrated outcomes similar to rubber band ligation.
The incidence of major complications in office procedures is rare.
Perianal sepsis is a life-threatening complication that can develop after office-based procedures or after anal surgery, in general.
Bleeding is the most common complication and occurs more often after rubber band ligation then other office-based procedures.
Some patients who undergo rubber band ligation will experience pain because of misplacement of the band near or below the dentate line.
Patients with thrombosed external hemorrhoids may benefit from early surgical excision.
Surgery may be superior to nonoperative treatment, but there is no evidence regarding the optimal period of initiation of conservative management.
Approximately 10% of patients with hemorrhoidal disease undergo surgery.
Excisional hemorrhoidectomy, which is the first line surgical treatment involves excision of abnormal hemorrhoidal tissue under anesthesia, using a closed procedure or open procedure.
Excision of thrombosed external hemorrhoids may result in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals.
Hemorrhoidectomy typically offered to patients whose symptoms result from external hemorrhoids or combined internal and external hemorrhoids with prolapse (grades III–IV).
Hemorrhoidectomy is effective for patients who fail or cannot tolerate office-based procedures, those who have grade III or IV hemorrhoids, or patients with substantial concomitant skin tags.
In a meta-analysis comparing hemorrhoidectomy with office-based procedures, hemorrhoidectomy was the most effective treatment for patients with grade III hemorrhoids, but is associated with increased pain and the highest complication rates.
Hemorrhoidectomy can be open or closed.
External hemorrhoidal disease rarely requires surgery unless acutely thrombosed.
Adverse effects of the excisional hemorrhoidectomy includes postop pain, bleeding, urinary retention, and fecal incontinence.
Outpatient clot evacuation within 72 hours of onset of a thrombosed external hemorrhoid is associated with decreased pain and reduced risk of repeat thrombosis.
The closed approach is associated with decreased postoperative pain, faster wound healing, and lesser risk of postoperative bleeding.
Postoperative complications, hemorrhoid recurrence, and infectious complications are similar on open and closed hemorrhoidectomy.
Complications after surgical hemorrhoidectomy are few, with the most common being postprocedure hemorrhage and most larger series reporting an incidence between 1% and 2%.
Acute urinary retention has been reported to occur between 1% and 15%.
Stapled hemorrhoidopexy uses a circular stapling device to create a mucosa-to-mucosa anastomosis.
Stapled hemorrhoidopexy excises the submucosa proximal to the dentate line, resulting in a relocation of the anal cushions and int2242uption of the feeding arteries.
Stapled hemorrhoidopexy is effective for internal prolapsing disease, it does not address external hemorrhoids.
Stapled hemorrhoidopexy is associated with less pain and faster recovery when compared with excisional hemorrhoidectomy, and surgical complication rates are similar between groups.
Excisional hemorrhoidectomy group has significantly better quality-of-life scores than the hemorrhoidopexy group, and significant reduction in recurrence rates.
Nonsignificant trends in favor of stapled hemorrhoidopexy were seen in pain, pruritus ani, and fecal urgency, but all of the other clinical parameters showed trends favoring excisional hemorrhoidectomy.
Excisional hemorrhoidectomy is recommended for grade III to IV prolapse, thrombosis, or mixed hemorrhoidal disease that does not improve with less invasive approaches.
Transanal hemorrhoid dearterializatiom, a minimally, invasive procedure involving ligating the arteries supplying blood to the diseased internal hemorrhoid tissue can reduce blood flow and promote regression overtime and has less discomfort than excisional hemorrhoidectomy, but a higher rate of recurrence.
Topical 2% Diltiazem ointment can reduce narcotic usage and pain scores after conventional hemorrhoidectomy.