Hemorrhoids

Definition, Etiology, PathogenesisTop

Hemorrhoids are vascular cushions in the anal canal, formed by the submucosa containing blood vessels (arteries and veins), smooth muscle, and connective tissue. Three main vascular cushions are located in the left lateral, right anterolateral, and right posterolateral positions. Hemorrhoids are a part of normal anatomy with the potential to become symptomatic.

Hemorrhoids are classified as internal or external hemorrhoids depending on their location relative to the dentate line (above or below the dentate line, respectively). Mixed hemorrhoids have both components.

Clinical FeaturesTop

The most common symptom of external hemorrhoids is perianal pain, which may occur when they thrombose. The most common symptom of internal hemorrhoids is rectal bleeding (bright red blood on toilet paper or dripping into the toilet bowl). It is rare, but possible, to have significant bleeding that causes anemia. Prolapse of hemorrhoidal tissue is another common symptom, felt as a perineal lump that occurs during and/or following bowel movements.

Classification of internal hemorrhoids based on the degree of prolapse:

1) Grade I: Enlargement of hemorrhoids without prolapse.

2) Grade II: Prolapse of hemorrhoids with spontaneous reduction.

3) Grade III: Prolapse of hemorrhoids requiring manual reduction.

4) Grade IV: Irreducible prolapse of hemorrhoids (ie, incarceration).

Sometimes patients report perianal pruritus. Sudden-onset pain is usually associated with thrombosed external hemorrhoids; it is rare in symptomatic internal hemorrhoids, unless there is a mixed component or incarceration of prolapsed internal hemorrhoids.

It is important to elicit information on bowel habits (ie, number of bowel habits, consistency of stool, incontinence, time sitting on toilet, straining) and any recent changes as well as family history of colorectal cancer or inflammatory bowel disease. Additionally, endoscopic history is an important consideration.

Physical examination includes inspection of the perianal region, digital rectal examination, and anoscopy/sigmoidoscopy. Careful examination should be done to exclude other pathology (eg, fissure, abscess, fistula in ano, dermatitis, condyloma, inflammatory bowel disease, malignancy).

DiagnosisTop

Physical examination and endoscopic visualization are usually sufficient for diagnosis.

Colonoscopy should be performed in patients with no obvious source of anorectal bleeding, with associated abdominal symptoms (eg, pain, distention, constipation), with rectal bleeding that is not typical for hemorrhoids (eg, blood mixed with feces, anemia), or if indicated for other clinical reasons (eg, family history of colorectal cancer). Patients who continue to experience rectal bleeding after successful treatment of presumed internal hemorrhoidal disease should undergo colonoscopy if not previously performed. The patient’s endoscopic history should also be considered when making a decision as to whether colonoscopy is required.

TreatmentTop

Treatment includes:

1) Lifestyle modification:

a) Dietary and lifestyle changes, including a high-fiber diet with fiber supplementation and increased water intake, are the first-line conservative management for symptomatic hemorrhoids.Evidence 1Strong recommendation (benefits clearly outweigh benefits; right action for all or almost all patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to the risk of bias of primary studies. Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004649. Review. PMID: 16235372. Hawkins AT, Davis BR, Bhama AR, et al; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024 May 1;67(5):614-623. doi: 10.1097/DCR.0000000000003276. Epub 2024 Jan 31. PMID: 38294832. Lifestyle modifications such as minimizing the time spent sitting on the toilet and straining should be adopted to decrease symptoms. Persistent symptoms can be reduced with these interventions, most notably in terms of bleeding. Prolapse, pain, and itching may improve minimally with these interventions.

b) Treatment of local symptoms (pruritus, burning sensation, pain) using warm sitz baths may be helpful. Suppositories/ointments containing ingredients such as local anesthetics and hydrocortisone have little data to support their use; however, some patients report relief.Evidence 2Conditional recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to the risk of bias of studies, observational nature of the data, and heterogeneity (variability in administration dose, site, and frequency of injections in the studies, as well as variability in healing rates reported in the studies). Hawkins AT, Davis BR, Bhama AR, et al; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024 May 1;67(5):614-623. doi: 10.1097/DCR.0000000000003276. Epub 2024 Jan 31. PMID: 38294832. Prolonged use of these topical ointments may cause allergic reactions and/or sensitivities.

2) Medical management: Phlebotonics are a heterogenous group of orally dosed medications derived from flavonoids that are thought to increase venous tone and strength of blood vessel walls. These medications have a safe adverse effect profile and may significantly improve symptom control.Evidence 3Weak recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Conditional recommendation (benefits likely outweigh downsides, but the balance is close or uncertain; an alternative course of action may be better for some patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to significant indirectness and heterogeneity (variability in administration dose, site, and frequency of injections in the studies, as well as variability in healing rates reported in the studies). Hawkins AT, Davis BR, Bhama AR, et al; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024 May 1;67(5):614-623. doi: 10.1097/DCR.0000000000003276. Epub 2024 Jan 31. PMID: 38294832. Perera N, Liolitsa D, Iype S, et al. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev. 2012 Aug 15;(8):CD004322. doi: 10.1002/14651858.CD004322.pub3. PMID: 22895941.

3) Endoscopic management/office-based procedures: In patients with grade I, II, and III hemorrhoids in whom medical treatment is ineffective, obliteration of hemorrhoidal tissue can be performed in an outpatient setting. Available endoscopic techniques include sclerotherapy, bipolar diathermy, infrared coagulation, and rubber band ligation. Rubber band ligation is the most common and effective method of office-based procedures, but it often requires multiple repeat treatments.Evidence 4Strong recommendation (benefits clearly outweigh benefits; right action for all or almost all patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to indirectness and heterogeneity. Hawkins AT, Davis BR, Bhama AR, et al; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024 May 1;67(5):614-623. doi: 10.1097/DCR.0000000000003276. Epub 2024 Jan 31. PMID: 38294832.  

4) Surgical management: Surgery by way of excisional hemorrhoidectomy is reserved for symptomatic hemorrhoids that have failed conservative and office-based procedures, grade IV hemorrhoids, or mixed hemorrhoids with a significant external component.Evidence 5Strong recommendation (benefits clearly outweigh benefits; right action for all or almost all patients). High Quality of Evidence (high confidence that we know true effects of the intervention). Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev. 2005 Oct 19;2005(4):CD004649. doi: 10.1002/14651858.CD004649.pub2. PMID: 16235372; PMCID: PMC9036624. Hawkins AT, Davis BR, Bhama AR, et al; Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024 May 1;67(5):614-623. doi: 10.1097/DCR.0000000000003276. Epub 2024 Jan 31. PMID: 38294832. Acutely incarcerated (nonreducible) or strangulated (vascular compromise) internal hemorrhoids require emergency excisional hemorrhoidectomy. Hemorrhoidectomy is the most effective treatment; however, it is associated with significant pain and potential serious complications. A number of different techniques exist, including open hemorrhoidectomy, closed hemorrhoidectomy, and stapled hemorrhoidectomy. Stapled hemorrhoidectomy is generally not recommended, given the associated increased risk of recurrence, decreased quality of life, and increased risk of developing stricture as compared with excisional hemorrhoidectomy. Doppler-guided hemorrhoid artery ligation is a novel surgical approach for symptomatic internal hemorrhoidal disease. It may be associated with decreased postoperative pain as compared with excisional hemorrhoidectomy but increased risk of recurrence. Metronidazole is effective at reducing postoperative pain following hemorrhoidectomy.

Thrombosed external hemorrhoids may require incision and evacuation of thrombus in patients who present within 72 hours of the onset of symptoms. Patients presenting later should be treated with analgesics and followed up without intervention because pain associated with thrombosis usually resolves spontaneously within 7 to 10 days. Most patients do not require any intervention.