Explain hemmorhoids
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Hemorrhoids
What Are They?
Hemorrhoids are dilated vascular cushions (plexuses of veins and arteriovenous connections) located in the anal canal and perirectal area. They are, in fact, a normal anatomical structure - everyone has them. The term "hemorrhoidal disease" refers to the pathological state when these cushions become symptomatic due to engorgement, prolapse, or thrombosis.
They affect an estimated 10-25% of the adult population, accounting for roughly 1.9-3.5 million physician visits per year in the USA.
- Sleisenger and Fordtran's Gastrointestinal and Liver Disease
- Robbins & Kumar Basic Pathology
Anatomy and Types
Hemorrhoids are classified based on their position relative to the dentate line (the mucocutaneous junction inside the anal canal):
| Type | Location | Lining | Sensation |
|---|---|---|---|
| Internal | Above the dentate line | Columnar/transitional mucosa | Usually painless |
| External | Below the dentate line | Squamous epithelium | Can be painful |
They typically occur in three positions: left lateral, right posterior, and right anterior. Hemorrhoids in other locations should raise concern for other diseases (carcinoma, lymphoma, condyloma).
The pathogenesis involves:
- Weakening and loss of connective tissue support (the suspensory ligament/Parks' ligament) anchoring the cushions
- Increased hydrostatic venous pressure
- In portal hypertension, they act as portocaval collaterals (similar mechanism to esophageal varices, but less dangerous)
Risk Factors / Predisposing Conditions
- Chronic constipation and straining
- Prolonged time sitting on the toilet
- Low-fiber diet
- Loose stools (paradoxically also a risk)
- Pregnancy and venous stasis
- Obesity
- Portal hypertension
Grading (Internal Hemorrhoids)
Internal hemorrhoids are graded by degree of prolapse:
| Grade | Description |
|---|---|
| I | Bleed and may be enlarged, but do not prolapse |
| II | Prolapse with defecation, reduce spontaneously |
| III | Prolapse and require manual reduction |
| IV | Remain permanently prolapsed, cannot be reduced |
Symptoms
- Bleeding - the most common symptom; typically bright red, painless, on tissue paper or dripping into the toilet; blood coats the outside of stool
- Prolapse - tissue protruding from the anus
- Perianal moisture/soiling - from prolapsed mucosa secreting mucus, leading to pruritus ani
- Pain - occurs primarily with thrombosis of external hemorrhoids; uncomplicated internal hemorrhoids are typically painless
- Swelling around the anus
Important: Patients often attribute all anal symptoms to hemorrhoids. Fissures, pruritus ani, fistulae, and cancer are frequently the actual cause - careful examination is essential.
Diagnosis
- History and physical examination - inspect and palpate the perianal area
- Anoscopy (beveled or slotted anoscope) - the primary tool for visualizing internal hemorrhoids and grading prolapse
- Digital rectal exam
- Colonoscopy or flexible sigmoidoscopy if rectal bleeding needs further evaluation (to rule out proximal pathology)
On histology, hemorrhoids show thin-walled, dilated submucosal vessels beneath the anal/rectal mucosa, subject to trauma, thrombosis, and inflammation.
Treatment
Treatment is stepwise, based on grade and symptom severity.
1. Conservative / Medical (All grades, first line)
- High-fiber diet (20-30 g/day) and increased fluid intake (6-8 glasses/day)
- Fiber supplements (psyllium, methylcellulose)
- Stool softeners - docusate sodium; polyethylene glycol 3350 for persistent constipation
- Sitz baths - warm water soaks for symptom relief
- Topical agents - phenylephrine/mineral oil/petrolatum or short-term glucocorticoid-based creams for pain/itch (caution: prolonged steroid use can cause local infection and skin atrophy)
- Phlebotonics (flavonoids such as diosmin/hesperidin) - improve venous tone and capillary permeability, reduce bleeding; superior to placebo for acute symptoms with an excellent safety profile
2. Office-Based Procedural (Grades I-III unresponsive to medical therapy)
| Procedure | Notes |
|---|---|
| Rubber band ligation (RBL) | Most common office procedure; applied above the dentate line; causes necrosis and scarring to fix mucosa; most effective for grades II-III |
| Injection sclerotherapy | Chemical fixation agent injected into submucosa |
| Infrared photocoagulation | Heat coagulates feeding vessels |
| Cryotherapy | Freezing to destroy tissue |
| Bipolar/direct current electrocoagulation | Electrical coagulation |
RBL key point: Bands must be placed above the dentate line. Placement on or below the dentate line (squamous mucosa) causes significant pain and requires immediate band removal.
3. Surgical (Grade IV, failed office procedures, thrombosed external hemorrhoids)
- Hemorrhoidectomy (excisional) - definitive treatment; considered the gold standard for severe disease
- Stapled hemorrhoidopexy (PPH) - less pain but higher recurrence
- Transanal hemorrhoidal dearterialization (THD/DGHAL) - Doppler-guided ligation of feeding arteries
- Thrombosed external hemorrhoids - excision within 72 hours of onset if pain is severe; after 72 hours, conservative management as symptoms typically resolve
Special Situations
- Pregnancy: Hemorrhoids are extremely common due to venous stasis and increased intra-abdominal pressure. Conservative management is the mainstay; most improve after delivery.
- Portal hypertension: Hemorrhoids can be a site of portocaval collateral circulation. Bleeding from portal hypertension-related hemorrhoids carries more serious implications.
- Thrombosed external hemorrhoids: Present with sudden onset of severe perianal pain and a tense, bluish perianal lump. If seen within 72 hours, excision under local anesthesia provides rapid relief.
Recent Evidence
A 2025 meta-analysis (PMID: 40596934) comparing surgical vs. conservative treatments for hemorrhoids found both approaches to be effective, with surgery offering better outcomes for higher-grade disease while conservative methods remain appropriate first-line treatment for lower grades.
Sources: Sleisenger & Fordtran's GI and Liver Disease | Clinical Gastrointestinal Endoscopy 3e | Robbins & Kumar Basic Pathology | Textbook of Family Medicine 9e
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