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Overview of hemorrhoids

Hemorrhoids remain one of the most common colorectal complaints. It has been estimated that 50% of the population has hemorrhoids by the age of 50 years.1 Hemorrhoidal disease results from the pathological enlargement and distal displacement of the upper hemorrhoidal plexus. Although they are often asymptomatic, hemorrhoids may cause bleeding, prolapse and pain.2

Current guidelines recommend a minimum of anoscopy and flexible sigmoidoscopy for bright-red rectal bleeding. Most hemorrhoid patients can be managed non-surgically. Surgery is reserved for patients with third and fourth-degree hemorrhoids and failure of nonoperative treatment. A new method of the stapled hemorrhoidectomy significantly reduces postoperative pain, hospital stay and use of analgesics.2


Classification of hemorrhoids 

Hemorrhoids can be broadly classified into internal and external. Internal hemorrhoids originate from the internal venous plexus above the dentate line while external hemorrhoids originate from the external plexus below the dentate line. The line lies at 2 cm from the anal verge and demarcates the transitionfrom the upper and the lower anal canal.

Internal hemorrhoids are classified according to the degreeof prolapse as following:
  • First degree—hemorrhoids bleed but do notprolapse.
  • Second degree—hemorrhoids prolapse on straining andreduce spontaneously.
  • Third degree—hemorrhoids prolapse onstraining and require manual reduction.
  • Fourth degree—hemorrhoidsare prolapsed and incarcerated.


Causes of hemorrhoids

The exact cause of hemorrhoids has not been determined. However, several factors contribute to their etiology. Low dietary fiber intake, malnutrition with constipation, reduced physical activity and hereditary predisposition seem to be the most relevant causes for pathogenesis.

Pregnancy and labor may aggravate the condition. Those whose occupations require heavy lifting or prolonged standing and individuals who overuse stimulant laxatives are other population at risk for hemorrhoids.


Presentation and Diagnosis of hemorrhoids

Signs and symptoms of hemorrhoids are the result of vascular congestion that occurs when veins become engorged secondary to obstructed blood flow. The symptoms include rectal bleeding, protrusion and swelling of tissue outside the anal canal and itching secondary to inflammation. These symptoms are nonspecific. Conditions such as inflammatory bowel disease and cancer can mimic hemorrhoidal symptoms. Unless the protrusion becomes thrombosed, infected or ulcerated, it is usually painless.

Patients with severe pain or incarcerated protrusions should be seen promptly. Diagnosis is established with direct visualization by anoscopy or proctoscopy. Since most bright red bleeding originate within the reach of a flexible sigmoidoscope, patients should undergo flexible sigmoidoscopy and anoscopy to rule out other causes of bleeding.

Management of hemorrhoids

Conservative treatment of hemorrhoids consists of dietary and lifestyle modifications. Patients are encouraged to sit in warm water or baths for 15 min, three to four times a day. The over-the-counter pharmacologic agents for symptomatic management of hemorrhoids include vasoconstrictors, astringents, protectants, local anesthetics, keratolytics, hydrocortisone and antipruritics.

Interventional procedures are performed in clinic to treat second and third degree hemorrhoids, and firstdegree hemorrhoids that do not respond to dietary modification. Standard interventional procedures are injection sclerotherapy and rubber band ligation. Among the surgical options for prolapsed hemorrhoids, conventional hemorrhoidectomy competes with stapled hemorrhoidopexy, which is less painful, has shorter convalescence and high patient satisfaction.1

The most important aspect of hemorrhoid management is prevention.

The following measures will help prevent hemorrhoids:

  • Avoid excessive pressure and straining during defecation

  • Increase intake of high-fiber diet

  • Drink plenty of water

  • Exercise

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Written by: Healthplus24 team
Date last updated: September 30, 2012