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. 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 to have significant bleeding that causes anemia. Prolapse of hemorrhoidal tissue is another common symptom.

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.

Sometimes patients report perianal pruritus. Sudden-onset pain is usually associated with thrombosed external hemorrhoids; it is rare in symptomatic internal hemorrhoids.

It is important to elicit information on bowel habits and any recent changes as well as family history of colorectal cancer or inflammatory bowel disease.

Physical examination includes inspection of the perianal region, digital rectal examination, and anoscopy. 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 anoscopy/sigmoidoscopy are usually sufficient for diagnosis.

Colonoscopy should be performed in patients 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).

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. PubMed PMID: 16235372. Lifestyle modifications such as minimizing the time spent on the toilet and straining should be adopted to decrease symptoms.

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.

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 2Weak 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). Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018 Mar;61(3):284-292. doi: 10.1097/DCR.0000000000001030. PMID: 29420423.

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.

4) Surgical management: Surgery is reserved for symptomatic hemorrhoids that have failed conservative and office-based procedures, grade IV hemorrhoids, or mixed hemorrhoids with a significant external component. 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. 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.