15-40: Hemorrhoids

Internal hemorrhoids are subepithelial vascular cushions consisting of connective tissue, smooth muscle fibers, and arteriovenous communications between terminal branches of the superior rectal artery and rectal veins. They are a normal anatomic entity, occurring in all adults, that contribute to normal anal pressures and ensure a water-tight closure of the anal canal. They commonly occur in three primary locations—right anterior, right posterior, and left lateral(eFigures 15–37 and 15–38). External hemorrhoids (eFigure 15–39) arise from the inferior hemorrhoidal veins located below the dentate line and are covered with squamous epithelium of the anal canal or perianal region.

Hemorrhoids may become symptomatic as a result of activities that increase venous pressure, resulting in distention and engorgement. Straining at stool, diarrhea, constipation, prolonged sitting, pregnancy, obesity, and low-fiber diets all may contribute. With time, redundancy and enlargement of the venous cushions may develop and result in bleeding or protrusion.

A. Symptoms and Signs

Patients often attribute a variety of perianal complaints to “hemorrhoids.” However, the principal problems attributable to internal hemorrhoids are bleeding, prolapse, and mucoid discharge. Bleeding is manifested by bright red blood that may range from streaks of blood visible on toilet paper or stool to bright red blood that drips into the toilet bowl after a bowel movement. Uncommonly, bleeding is severe and prolonged enough to result in anemia. Initially, internal hemorrhoids are confined to the anal canal (stage I). Over time, the internal hemorrhoids may gradually enlarge and protrude from the anal opening. At first, this mucosal prolapse occurs during straining and reduces spontaneously (stage II). With progression over time, the prolapsed hemorrhoids may require manual reduction after bowel movements (stage III) or may remain chronically protruding (stage IV). Chronically prolapsed hemorrhoids may result in a sense of fullness or discomfort and mucoid discharge, resulting in irritation of perianal skin and soiling of underclothes. Pain is unusual with internal hemorrhoids, occurring only when there is extensive inflammation and thrombosis of irreducible tissue or with thrombosis of an external hemorrhoid.

B. Examination

External hemorrhoids are readily visible on perianal inspection. Nonprolapsed internal hemorrhoids are not visible but may protrude through the anus with gentle straining while the clinician spreads the buttocks. Prolapsed hemorrhoids are visible as protuberant purple nodules covered by mucosa. The perianal region should also be examined for other signs of disease such as fistulas, fissures, skin tags, condyloma, anal cancer, or dermatitis. On digital examination, uncomplicated internal hemorrhoids are neither palpable nor painful. Anoscopic evaluation, best performed in the prone jackknife position, provides optimal visualization of internal hemorrhoids.

Small volume rectal bleeding may be caused by an anal fissure or fistula, neoplasms of the distal colon or rectum, ulcerative colitis or Crohn colitis, infectious proctitis, or rectal ulcers. Rectal prolapse, in which a full thickness of rectum protrudes concentrically from the anus, is readily distinguished from mucosal hemorrhoidal prolapse. Proctosigmoidoscopy or colonoscopy should be performed in all patients with hematochezia to exclude disease in the rectum or sigmoid colon that could be misinterpreted in the presence of hemorrhoidal bleeding.

A. Conservative Measures

Most patients with early (stage I and stage II) disease can be managed with conservative treatment. To decrease straining with defecation, patients should be given instructions for a high-fiber diet and told to increase fluid intake with meals, avoid straining, and limit sitting time on the toilet to less than 5 minutes. Dietary fiber may be supplemented with bran powder (1–2 tbsp twice daily added to food or in 8 oz of liquid) or with commercial bulk laxatives (eg, Benefiber, Metamucil, Citrucel). Suppositories and rectal ointments have no demonstrated utility in the management of mild disease. Mucoid discharge may be treated effectively by the local application of a cotton ball tucked next to the anal opening after bowel movements.

B. Medical Treatment

Patients with stage I, stage II, and stage III hemorrhoids and recurrent bleeding despite conservative measures may be treated without anesthesia with injection sclerotherapy, rubber band ligation, or application of electrocoagulation (bipolar cautery or infrared photocoagulation). The choice of therapy is dictated by operator preference, but rubber band ligation is preferred due to its ease of use and high rate of efficacy. Major complications occur in less than 2%, including pelvic sepsis, pelvic abscess, urinary retention, and bleeding. Recurrence is common unless patients alter their dietary habits. Edematous, prolapsed (stage IV) internal hemorrhoids, may be treated acutely with topical creams, foams, or suppositories containing various combinations of emollients, topical anesthetics, (eg, pramoxine, dibucaine), vasoconstrictors (eg, phenylephrine), astringents (witch hazel), and corticosteroids. Common preparations include Preparation H (several formulations), Anusol HC, Proctofoam, Nupercainal, Tucks, and Doloproct (not available in the United States).

C. Surgical Treatment

Surgical excision (hemorrhoidectomy) is reserved for less than 5–10% of patients with chronic severe bleeding due to stage III or stage IV hemorrhoids or patients with acute thrombosed stage IV hemorrhoids with necrosis. Complications of surgical hemorrhoidectomy include postoperative pain (which may persist for 2–4 weeks) and impaired continence.

Thrombosis of the external hemorrhoidal plexus results in a perianal hematoma. It most commonly occurs in otherwise healthy young adults and may be precipitated by coughing, heavy lifting, or straining at stool. The condition is characterized by the relatively acute onset of an exquisitely painful, tense and bluish perianal nodule covered with skin that may be up to several centimeters in size. Pain is most severe within the first few hours but gradually eases over 2–3 days as edema subsides. Symptoms may be relieved with warm sitz baths, analgesics, and ointments. With symptom resolution, a perianal skin tag may persist, which can be a source of irritation. If the patient is evaluated in the first 24–48 hours, removal of the clot may hasten symptomatic relief. With the patient in the lateral position, the skin around and over the lump is injected subcutaneously with 1% lidocaine using a tuberculin syringe with a 30-gauge needle. An ellipse of skin is then excised and the clot evacuated. A dry gauze dressing is applied for 12–24 hours, and daily sitz baths are then begun.

• Stage I, II, or III: When conservative measures fail and expertise in medical procedures is needed (injection, banding, thermocoagulation).

• Stage IV: When surgical excision is required.