Hemorrhoids

Key Features

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

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

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

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