Dilated sinusoids classified as internal, external or mixed.

May develop inside the anus and protrude outside or appear outside the anus and be coverd by skin.

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.

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.

Symptoms occur when the veins around the anus becomes swollen and irritated and can cause mucoid discharge, bleeding, swelling, and/or itching.
Severe pain with defecation is not usually associated with internal hemorrhoids, except when acute thrombosis is present.
The amount of localized anal rectal bleeding and mucoid discharge is variable in hemorrhoidal disease, whereas in anal fissures, bleeding is scant and mucoid discharge is usually absent.
Distinguishing between hemorrhoidal disease and anal fissures is difficult because patients present with many of the same overlapping symptoms, it is important because the management of the two conditions are very different.

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.

Simple treatments include: warm baths, and topical medication measures.

Hemorrhoidectomy may be required in severe cases.

Treatments include: sclero therapy, rubber band ligation, infrared photo-coagulation, stapled hemorrhoidectomy, and excisional hemorrhoidectomy.

Rubber band ligation associated with 89% patient satisfaction at 3 years.

Management of Hemorrhoids

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,

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.

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.

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.

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.

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.

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.

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.

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.

Topical 2% Diltiazem ointment can reduce narcotic usage and pain scores after conventional hemorrhoidectomy.

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