This endoscopic clinical photograph demonstrates Grade III internal hemorrhoids within the rectum before and after sclerotherapy treatment. Image A (pre-treatment) shows a retroflexed view of the anal canal where a prominent, swollen, pale-gray mass is visible, indicated by a black arrow. The hemorrhoid exhibits an irregular, nodular surface texture with dark vertical vascular striations, protruding into the lumen from the surrounding reddish-pink rectal mucosa. Image B (post-treatment) displays the clinical response following sclerotherapy. There is a marked reduction in the size and protrusion of the hemorrhoidal tissue. The previously bulky mass appears flattened and less congested, although some minor surface blood and residual dark vascular markings remain visible. This comparison illustrates the efficacy of sclerotherapy in reducing the volume and vascularity of prolapsing internal hemorrhoidal disease, which is a common minimally invasive intervention for symptomatic, non-bleeding Grade II and III hemorrhoids.

This composite of three clinical photographs provides a visual comparison between full-thickness rectal prolapse and prolapsed internal hemorrhoids, serving as an educational tool for proctological diagnosis. Panel A (posterior view) and Panel B (lateral view) demonstrate a complete rectal prolapse. The images show a large, reddish-pink, cylindrical mass protruding from the anal canal. A pathognomonic feature is the presence of concentric, circular mucosal folds, which distinguish it from other pathologies. Panel C depicts prolapsed internal hemorrhoids. This view shows three distinct, elongated, reddish-purple masses arranged radially within the anal region. Unlike the rectal prolapse in A and B, these masses demonstrate longitudinal or radial folds and are separated by grooves, corresponding to the left lateral, right anterolateral, and right posterolateral anatomical positions. Some surface moisture and vascular congestion are visible. This clinical imagery is essential for differentiating pelvic floor disorders and anorectal conditions based on fold orientation and morphology.

This composite of two endoscopic images demonstrates common rectal pathologies. The top image shows a Solitary Rectal Ulcer (SRU), characterized by a shallow, irregular-shaped lesion with a pale, whitish-grey fibrin base and surrounding erythematous, hyperemic mucosa. The lesion appears flat rather than excavated. The bottom image shows internal hemorrhoids, appearing as multiple, prominent, bulging columns of tissue protruding into the rectal lumen. These hemorrhoids exhibit significant vascular congestion, visible as a deep red or purplish discoloration with a smooth, glistening mucosal surface. The images illustrate the clinical distinction between ulcerative inflammatory processes and vascular-based structural abnormalities in the anorectal region. These findings are clinically significant in the diagnostic workup for symptoms such as bleeding per rectum, tenesmus, and chronic constipation. The content is suitable for medical students and gastroenterology trainees learning to identify anorectal disorders via lower gastrointestinal endoscopy.

<table> <tr> <td colspan="2"><b>Table 11.</b> Current concepts of hemorrhoids</td> </tr> <tr> <td>1</td> <td>The cardinal signs of internal hemorrhoids are painless bleeding and intermittent protrusion. The diagnosis generally requires the exclusion of other conditions that can produce similar symptoms.</td> </tr> <tr> <td>2</td> <td>Internal hemorrhoids are assigned a functional grade based on their history: First-degree hemorrhoids do not prolapse; second-degree hemorrhoids prolapse but spontaneously reduce; third-degree hemorrhoids prolapse and require manual reduction; and fourth-degree hemorrhoids protrude and cannot be reduced.</td> </tr> <tr> <td>3</td> <td>External hemorrhoids may become thrombosed by developing a clot in a vein under the squamous epithelium of the anal verge.</td> </tr> </table>

This composite visual represents the Rafaelo® procedure for the treatment of internal hemorrhoids using radiofrequency ablation. Panel (a) is a schematic diagram illustrating the anatomical positioning: a proctoscope is inserted into the anal canal, through which a radiofrequency probe is guided into the hemorrhoidal plexus above the dentate line. A protective layer of local anesthetic is shown injected between the submucosa and the internal sphincter muscle to prevent thermal injury. Panel (b) is a clinical photograph taken via proctoscopy showing the real-time insertion of the fine-needle probe tip into the protruding hemorrhoidal tissue. Panel (c) demonstrates the post-ablation state of the tissue. Visible hallmarks of successful treatment include mucosal blanching (lightening of tissue color) and localized coagulation points on the hemorrhoid surface, indicating thermal denaturation of proteins. The procedure aims to induce tissue fibrosis and subsequent retraction of the hemorrhoidal prolapse, minimizing post-operative pain and avoiding open surgical wounds.

This composite of three clinical photographs documents an intraoperative RAFAELO procedure for internal hemorrhoids. Panel 4A shows the preoperative surgical field with the patient in a prone or lithotomy position, draped with green surgical sheets. The perianal skin is prepped with an orange-tinted antiseptic solution. Panel 4B displays an intraoperative proctoscopy view using a clear plastic proctoscope. A black arrow identifies a prominent, erythematous, fleshy Grade II internal hemorrhoid cushion protruding into the rectal lumen at the 5 o'clock position. Panel 4C shows the post-procedure proctoscopy view following radiofrequency ablation. The targeted hemorrhoidal tissue (indicated by the arrow) appears visibly reduced in volume, less edematous, and significantly more retracted compared to the preoperative state. These images serve as educational material for colorectal surgery, illustrating the visual markers of successful radiofrequency treatment for symptomatic internal hemorrhoids.

This composite of three clinical photographs documents a surgical hemorrhoidectomy procedure for Grade III or IV hemorrhoids. Panel A shows the preoperative state with significant prolapsed, irregular, reddish-brown hemorrhoidal piles protruding from the anal canal; surgical forceps are used to retract and demonstrate the extent of the prolapse. Panel B illustrates the intraoperative phase, showing the use of a circular white anal dilator to manage internal anal sphincter hypertonicity and provide surgical access to the hemorrhoidal columns. Panel C displays the immediate postoperative result, demonstrating a restored anal anatomy with no visible protruding tissue. The surgical site shows radial suture lines where the hemorrhoidal masses were excised and the mucosa was closed with simple interrupted sutures. This sequence highlights the surgical transition from symptomatic prolapse through intraoperative dilation to postoperative anatomical correction, serving as an educational resource for colorectal surgery and proctology.

This composite diagnostic image illustrates a Type I anal fistula using two different modalities: 3D pelvic ultrasound (US) and magnetic resonance imaging (MRI). Image A shows a transrectal or pelvic 3D US presenting a heterogeneous perianal region. A red arrow indicates a hypoechoic, cavity-like tract representing the fistula, with calipers measuring its dimensions (1.87 cm and 1.46 cm). Image B is an axial T2-weighted or fat-suppressed MRI of the pelvic floor and anal canal. A blue arrow highlights a hyperintense (bright) signal adjacent to the anal canal, indicating an active inflammatory fistula tract or fluid collection. The comparison demonstrates the clinical utility of both US and MRI in identifying perianal fistulous disease, highlighting the fistula's spatial relationship to pelvic musculature and the anal canal. The images are aimed at an intermediate to advanced medical level, focusing on radiologic diagnosis and classification of anorectal pathologies.

This composite of five axial pelvic MRI scans (labeled A-E) demonstrates a Grade 4 trans-sphincteric perianal fistula with secondary ramification, categorized according to the St. James’s University Hospital classification system. Images A and D utilize STIR (Short Tau Inversion Recovery) sequences, showing the fistula as a hyperintense, fluid-filled tract originating near the 6 o'clock position of the anal canal and crossing the external sphincter. Image B and E are post-contrast fat-suppressed T1-weighted images (T1-WI) showing prominent enhancement of the tract walls, indicating active inflammation. Image C is a Diffusion-Weighted Image (DWI) showing restricted diffusion, which appears as a high-signal (bright) intensity, highlighting the active fistula components. White arrows in all panels identify the primary tract, while panels D and E specifically reveal a secondary ramification branching posteriorly. This diagnostic imaging series is designed for radiology and surgical residents to understand the multi-parametric MRI appearance of complex fistulous disease, including the identification of internal openings and secondary tracts essential for surgical planning.

A comparative diagnostic image display showing a Type II anal fistula through two different imaging modalities: (A) a transverse pelvic 3D Ultrasound (US) and (B) an axial Magnetic Resonance Image (MRI). In image A, the 3D ultrasound demonstrates the fistula as a hypoechoic (dark) focal area within the heterogeneous pelvic floor tissue, indicated by a white arrow; a caliper measurement 'D1' shows a width of 0.28 cm. In image B, the MRI (likely T2-weighted or STIR) reveals the fistula as a hyperintense (bright) linear structure, indicated by a yellow arrow, situated within the midline anatomical structures near the anal canal. The surrounding pelvic floor musculature, including the levator ani and external sphincter regions, are visible as darker, well-defined tissues. This comparison illustrates the diagnostic visualization of perianal inflammatory tracks and is used in colorectal surgery planning for classification and localization of fistulous tracts relative to the sphincter complex.