Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 15-40: Hemorrhoids + Key Features Download Section PDF Listen +++ +++ Essentials of Diagnosis ++ Bright red blood per rectum Protrusion of tissue from anus, with discomfort Characteristic findings on external anal inspection and anoscopy +++ General Considerations ++ 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 External hemorrhoids arise from the inferior hemorrhoidal veins located below the dentate line and are covered with squamous epithelium of the anal canal or perianal region Causes include Straining at stool Diarrhea Constipation Prolonged sitting Pregnancy Obesity Low-fiber diet + Clinical Findings Download Section PDF Listen +++ +++ Symptoms and Signs ++ Bright red blood per rectum Streaks of blood visible on toilet paper or stool, or bright red blood that drips Uncommonly, severe and prolonged enough to cause anemia Mucoid discharge Internal hemorrhoids May gradually enlarge and protrude Prolapsed hemorrhoids appear as protuberant purple nodules covered by mucosa Discomfort and pain are unusual, occurring only when there is extensive inflammation and thrombosis of irreducible tissue External hemorrhoids Readily visible on perianal inspection or may protrude through the anus with gentle straining Usually asymptomatic, though may interfere with perianal hygiene Acute thrombosis causes severe pain 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 Thrombosed external hemorrhoid Appears as 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 +++ Differential Diagnosis ++ Rectal prolapse Anal fissure Anal skin tag Perianal fistula or abscess, eg, Crohn disease Infectious proctitis, eg, gonorrhea Anogenital warts (condyloma acuminata) Perianal pruritus Proctalgia fugax or levator ani syndrome Lower gastrointestinal bleeding due to other cause, eg, diverticulosis, polyps, colorectal cancer + Diagnosis Download Section PDF Listen +++ +++ Diagnostic Procedures ++ Anoscopy: visualization of internal hemorrhoids Grading I: No prolapse II: Prolapse with defecation; spontaneously reduces III: Prolapse with defecation or other times; requires manual reduction IV: Permanently prolapsed mucosal tissue; visible externally + Treatment Download Section PDF Listen +++ +++ Surgery ++ Surgical excision (hemorrhoidectomy) for patients with grade IV hemorrhoids with persistent bleeding or discomfort +++ Therapeutic Procedures ++ Patients with stages I–III hemorrhoids and recurrent bleeding despite conservative measures may be treated without anesthesia with Injection sclerotherapy Rubber band ligation (preferred due to ease of use and high efficacy rate) Application of electrocoagulation (bipolar cautery or infrared photocoagulation) +++ Conservative measures ++ High-fiber diet Increase fluid intake Application of a cotton ball tucked next to the anal opening after bowel movements for mucoid discharge Symptomatic relief of prolapsed hemorrhoids by suppositories (eg, Anusol with or without hydrocortisone) Warm sitz baths +++ Thrombosed external hemorrhoid ++ Warm sitz baths Analgesics Ointments Incision to remove the clot may hasten symptomatic relief + Outcome Download Section PDF Listen +++ +++ Follow-Up ++ Bleeding usually subsides after 1–3 sessions of sclerotherapy or rubber band ligation +++ Complications ++ Major complications from injection sclerotherapy, rubber band ligation, or electrocoagulation occur in < 2% and include Pelvic sepsis Pelvic abscess Urinary retention Bleeding +++ Prognosis ++ Recurrence is common after injection sclerosis or banding +++ Prevention ++ High-fiber diet Stool softeners to prevent straining at stool +++ When to Refer ++ 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 +++ When to Admit ++ Severe bleeding with anemia (rare) Incarcerated, thrombosed grade IV internal hemorrhoids Pelvic cellulitis after banding or sclerotherapy + References Download Section PDF Listen +++ + +Jamshidi R. Anorectal complaints: hemorrhoids, fissures, abscesses, fistulae. Clin Colon Rectal Surg. 2018 Mar;31(2):117–20. [PubMed: 29487494] + +Qureshi WA. Office management of hemorrhoids. Am J Gastroenterol. 2018 Jun;113(6):795–8. [PubMed: 29487411] + +Sandler RS et al. Rethinking what we know about hemorrhoids. Clin Gastroenterol Hepatol. 2019 Jan;17(1):8–15. [PubMed: 29601902] + +Yang JY et al. Burden and cost of outpatient hemorrhoids in the United States employer-insured population, 2014. Am J Gastroenterol. 2019 May;114(5):798–803. [PubMed: 30741736]