Introduction
Hemorrhoids have plagued humankind since time immemorial, yet many misunderstandings regarding hemorrhoidal complaints and disease still exist. Many laypersons and clinicians do not understand the anorectal area and the common diseases associated with it.
This article discusses internal and external hemorrhoids and their associated symptoms.
For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Hemorrhoids, Inflammatory Bowel Disease, Rectal Pain, and Rectal Bleeding.
Recent studies
In a study of 198 physicians from different specialties, Grucela et al evaluated diagnostic accuracy for 7 common, benign anal pathologic conditions, including anal abscess, fissure, and fistula; prolapsed internal hemorrhoid; thrombosed external hemorrhoid; condyloma acuminata; and full-thickness rectal prolapse. Physicians in the study were shown images of these conditions, after which they provided written diagnoses. The investigators found the overall diagnostic accuracy among the physicians to be 53.5%, with the accuracy for surgeons being 70.4% and that for the rest of the doctors being less than 50%. The rate of correct identification was greatest for condylomata and rectal prolapse and was lowest for hemorrhoidal conditions. The authors also found no correlation between diagnostic accuracy and years of physician experience. Grucela et al recommended that physician education concerning common, benign anal disorders be improved.1
Frequency
Up to one third of the 10 million people in the United States with hemorrhoids seek medical treatment, resulting in 1.5 million related prescriptions per year.
The number of hemorrhoidectomies performed in hospitals is declining. A peak of 117 hemorrhoidectomies per 100,000 people was reached in 1974; this rate declined to 37 hemorrhoidectomies per 100,000 people in 1987. Obviously, outpatient and office treatment of hemorrhoids account for some of this decline.
Hemorrhoids plague all age groups, although they occur most often in individuals aged 46-65 years.
Etiology
Hemorrhoidal complaints are usually not associated with other medical conditions or diseases. However, patients with the following diseases and conditions have an increased risk of hemorrhoidal complaints:
- Inflammatory bowel disease and hemorrhoidal problems occur frequently. Unusual hemorrhoidal presentations and findings should alert the clinician to the potential of inflammatory bowel disease.
- Ulcerative colitis and Crohn disease are associated with hemorrhoids.
- Pregnancy is associated with many anorectal problems.
Pathophysiology
The term hemorrhoid is usually related to the symptoms caused by hemorrhoids. Hemorrhoids are present in healthy individuals. In fact, hemorrhoidal columns exist in utero. When these vascular cushions produce symptoms, they are referred to as hemorrhoids. Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed.
Most authors agree that low-fiber diets cause small-caliber stools, which result in straining during defecation. This increased pressure causes engorgement of the hemorrhoids, possibly by interfering with venous return. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause hemorrhoidal problems, presumably by means of the same mechanism. Decreased venous return is thought to be the mechanism of action. Prolonged sitting on a toilet (eg, while reading) is believed to cause a relative venous return problem in the perianal area (a tourniquet effect), resulting in enlarged hemorrhoids. Aging causes weakening of the support structures, which facilitates prolapse. Weakening of support structures can occur as early as the third decade of life.
Straining and constipation have long been thought of as culprits in the formation of hemorrhoids. This may or may not be true.2,3,4 Patients who report hemorrhoids have a canal resting tone that is higher than normal. Of interest, the resting tone is lower after hemorrhoidectomy than it is before the procedure. This change in resting tone is the mechanism of action of Lord dilatation, a surgical procedure for anorectal complaints that is most commonly performed in the United Kingdom.
Pregnancy clearly predisposes women to symptoms from hemorrhoids, although the etiology is unknown. Notably, most patients revert to their previously asymptomatic state after delivery. The relationship between pregnancy and hemorrhoids lends credence to hormonal changes or direct pressure as the culprit.
Portal hypertension has often been mentioned in conjunction with hemorrhoids.5,6,7 Hemorrhoidal symptoms do not occur more frequently in patients with portal hypertension than in those without it. Massive bleeding from hemorrhoids in these patients is unusual. Bleeding is very often complicated by coagulopathy. If bleeding is found, direct suture ligation of the offending column is suggested.
Anorectal varices are common in patients with portal hypertension.8 Varices occur in the midrectum, at connections between the portal system and the middle and inferior rectal veins. Varices occur more frequently in patients who are noncirrhotic, and they rarely bleed. Treatment is usually directed at the underlying portal hypertension. Emergent control of bleeding can be obtained with suture ligation. Portosystemic shunts and transjugular intrahepatic portosystemic shunts (TIPS) have been used to control hypertension and thus, the bleeding.9
Presentation
Most laypersons and many practitioners attribute all perianal symptoms to hemorrhoids. The astute clinician can often listen to a patient's description of symptoms and ascertain the source of the problem or condition before confirmatory examination. Nonhemorrhoidal causes of symptoms (eg, fissure, abscess, fistula, pruritus ani, condylomata, and viral or bacterial skin infection) need to be excluded.
Hemorrhoidal symptoms are divided into internal and external sources.
Internal hemorrhoids cannot cause cutaneous pain, because they are above the dentate line and are not innervated by cutaneous nerves. However, they can bleed, prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal skin, cause perianal itching and irritation. Internal hemorrhoids can produce perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. This spasm results in discomfort while the prolapsed hemorrhoids are exposed. This muscle discomfort is relieved with reduction.
Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes concomitant external thrombosis. External thrombosis causes acute cutaneous pain. This consternation of symptoms is referred to as acute hemorrhoidal crisis. It usually requires emergent treatment.
Internal hemorrhoids most commonly cause painless bleeding with bowel movements. The covering epithelium is damaged by the hard bowel movement, and the underlying veins bleed. With spasm of the sphincter complex elevating pressure, the internal hemorrhoidal veins can spurt.
Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This mucus with microscopic stool contents can cause a localized dermatitis, which is called pruritus ani. Generally, hemorrhoids are merely the vehicle by which the offending elements reach the perianal tissue. Hemorrhoids are not the primary offenders.
External hemorrhoids cause symptoms in 2 ways. First, acute thrombosis of the underlying external hemorrhoidal vein can occur. Acute thrombosis is usually related to a specific event, such as physical exertion, straining with constipation, a bout of diarrhea, or a change in diet. These are acute, painful events. Pain results from rapid distension of innervated skin by the clot and surrounding edema. The pain lasts 7-14 days and resolves with resolution of the thrombosis. With this resolution, the stretched anoderm persists as excess skin or skin tags. External thromboses occasionally erode the overlying skin and cause bleeding. Recurrence occurs approximately 40-50% of the time, at the same site (because the underlying damaged vein remains there). Simply removing the blood clot and leaving the weakened vein in place, rather than excising the offending vein with the clot, will predispose the patient to recurrence.
External hemorrhoids can also cause hygiene difficulties, with the excess, redundant skin left after an acute thrombosis (skin tags) being accountable for these problems. External hemorrhoidal veins found under the perianal skin obviously cannot cause hygiene problems; however, excess skin in the perianal area can mechanically interfere with cleansing.
Indications
Treat hemorrhoids only when the patient complains of them. The old adage that it is hard to make an asymptomatic patient better applies here. No matter how bad the hemorrhoids look to the practitioner, they should not be treated unless they bother the patient.
Relevant Anatomy
Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg, arterioles, venules, arteriolar-venular connections), smooth muscle (eg, Treitz muscle), and connective tissue lined by the normal epithelium of the anal canal. Hemorrhoids are present in utero and persist through normal adult life. Evidence indicates that hemorrhoidal bleeding is arterial and not venous. This evidence is supported by the bright red color and arterial pH of the blood.
Hemorrhoids are categorized into internal and external hemorrhoids. These categories are anatomically separated by the dentate (pectinate) line. External hemorrhoids are hemorrhoids covered by squamous epithelium, whereas internal hemorrhoids are lined with columnar epithelium. Similarly, external hemorrhoids are innervated by cutaneous nerves that supply the perianal area. These nerves include the pudendal nerve and the sacral plexus. Internal hemorrhoids are not supplied by somatic sensory nerves and therefore cannot cause pain. At the level of the dentate line, internal hemorrhoids are anchored to the underlying muscle by the mucosal suspensory ligament.
Internal hemorrhoids have 3 main cushions, which are situated in the left lateral, right posterior, and right anterior areas of the anal canal. Minor tufts can be found between the major cushions.
External hemorrhoidal veins are found circumferentially under the anoderm; they can cause trouble anywhere around the circumference of the anus.
Contraindications
Care must be taken to ensure that symptoms are not caused by other perianal conditions (eg, fissure, fistula, infectious disease, inflammatory bowel disease, parasites). Obviously, treating hemorrhoids will not help these problems. Frequently, a thorough history can eliminate the above conditions.
Inflammatory bowel diseases (eg, ulcerative colitis, Crohn disease) need to be ruled out as the cause of symptoms. Human immunodeficiency virus (HIV) infection and other immunosuppressive diseases also can alter treatment plans.
More on Hemorrhoids |
 Overview: Hemorrhoids |
| Workup: Hemorrhoids |
| Treatment: Hemorrhoids |
| Follow-up: Hemorrhoids |
| References |
| Further Reading |
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References
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Further Reading
Related eMedicine topics:
Constipation [Emergency Medicine]
Constipation [Gastroenterology]
Constipation [Pediatrics: General Medicine]
Constipation and Bowel Management
Crohn Disease [Gastroenterology]
Crohn Disease [Pediatrics: General Medicine]
Crohn Disease [Radiology]
Hemorrhoids [Emergency Medicine]
Inflammatory Bowel Disease [Emergency Medicine]
Inflammatory Bowel Disease [Gastroenterology]
Inflammatory Bowel Disease [Ophthalmology]
Portal Hypertension [Gastroenterology]
Portal Hypertension [Radiology]
Rectal Prolapse [Emergency Medicine]
Rectal Prolapse [General Surgery]
Rectal Prolapse [Pediatrics: General Medicine]
Rectal Prolapse: Surgical Perspective
Thrombosed External Hemorrhoid Excision
Ulcerative Colitis [Gastroenterology]
Ulcerative Colitis [Pediatrics: General Medicine]
Ulcerative Colitis [Radiology]
Clinical guidelines:
Practice parameters for the management of hemorrhoids (revised). American Society of Colon and Rectal Surgeons - Medical Specialty Society. 1993 (revised 2005 Feb). 6 pages. NGC:004337
Practice parameters for the treatment of perianal abscess and fistula-in-ano (revised). American Society of Colon and Rectal Surgeons - Medical Specialty Society. 1996 (revised 2005 Jul). 6 pages. NGC:004432
Stapled haemorrhoidopexy for the treatment of haemorrhoids. National Institute for Health and Clinical Excellence (NICE) - National Government Agency [Non-U.S.]. 2007 Sep
Clinical studies:
EnSeal Device Versus Ferguson Technique in Hemorrhoidectomy
Is Doppler Necessary in Haemorrhoidal Artery Ligation Operation?
Prospective Randomized Trial Comparing THD Versus Stapler Operation for 3rd Degree Hemorrhoids (THD/stapler)
Recto Anal Repair or Milligan Morgans Operation of Grade 3 and 4 Symptomatic Haemorrhoidal Disease
Study of a New Circular Anal Dilator
Keywords
hemorrhoids, piles, hemorrhoid, external hemorrhoids, internal hemorrhoids, hemorrhoids treatment, external hemorrhoid, hemorrhoids surgery, hemorrhoidectomy, hemorrhoidal, hemorrhoids pregnancy, bleeding hemorrhoids, thrombosed hemorrhoids, hemorrhoids cure, hemorrhoids symptoms, hemorrhoids cause, hemorrhoids pain, internal hemorrhoid, prolapsed hemorrhoid
