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A. Introduction

  1. Hemorrhoids are highly dilated arteriovenous complexes
  2. They can be seen through surface mucousa as purple tubular structures
  3. Primarily in persons >40 years old and in pregnant women
  4. Symptomatic in >50% of persons over 50 years old
  5. Most common cause of rectal pain and/or bleeding in general population
  6. Other (more serious) causes must be ruled out [2]

B. Anatomy and Etiology

  1. Hemorrhoids may be external or internal
    1. The dentate (pectinate) line is at the junction of squamous and columnar epithelium
    2. Classification is based on origin of the hemorrhoid, above or below dentate line
    3. External hemorrhoids originate below the dentate line
    4. Internal hemorrhoids originate above the dentate line, although they may protrude
  2. External pain fibers terminate at the dentate line
    1. Manipulation of external hemorrhoids is usually extremely painful
    2. There is little sensation above the dentate line
    3. Manipulation of internal hemorrhoids is usually not painful
  3. Hemorrhoids are highly dilated arteriovenous plexi of the anorectal region
  4. Occur at right anterior, right posterior, and left lateral positions
  5. Etiology: unclear. Familial tendincy, usually in patients with constipation.

C. Symptoms

  1. External Hemorrhoids are extremely painful, especially with bowel movements
  2. Internal Hemorrhoids
    1. Mainly depends on grade (see below)
    2. Bleeding and palpable, protruding mass are most common
    3. Pain is less common, usually only in patients with thrombosed hemorrhoids
  3. Uncommon: pruritis, pain with internal hemorrhoids

D. Differential Diagnosis

  1. Anal Fissure - pain with defacation, usually taring or burning
  2. Perirectal Abscess - associated with immunocompromise, frequent anal intercourse
  3. Anal Fistulae - inflammatory bowel disease
  4. Perineal Condylomas
    1. Associated with human papilloma virus (HPV)
    2. Increased with anal intercourse
  5. Anal or Rectal Carcinoma
  6. Arteriovenous Malformation - usually more proximal; bleeding is main symptoms
  7. Pruritis ani - dermatitis, candidiasis, HPV, scarring due to scratching, pinworm, etc.
  8. A careful history and physical exam must be carried out in all bleeding cases
    1. In general, evaluation of rectal bleeding should include at least sigmoidoscopy
    2. In a 10-year followup study, 24% of patients with rectal bleeding had serious disease [2]
    3. Double-contrast (barium/air) enema may be combined with sigmoidoscopy

E. Grades of Internal Hemorrhoids

  1. Depends on amount of prolapse (extent to which hemorrhoid descends out of the anus)
  2. Grade I - localized internal hemorrhoids, rarely symptomatic (minor bleeding)
  3. Grade II - prolapse with bowel movement, return spontaneously
  4. Grade III - require manual replacement
  5. Grade IV - tissue remains outside of anus; cannot be replaced manually

F. Evaluation

  1. Anoscopy is the major method of visualizing hemorrhoids
  2. Hemorrhoids usually occur at defined positions (see above)
  3. Fissures are usually midline
  4. Flexible sigmoidoscopy should be strongly considered to rule out accompanying pathology

G. Overview of Treatment [1]

  1. External
    1. Observation
    2. Local measures
    3. Surgical Excision
    4. Thrombosed: observation, incision, or excision
  2. Internal
    1. Band Ligation
    2. Infrared coagulation
    3. Radiofrequency treatment
    4. Sclerotherapy
    5. Surgical excision / laser
  3. Anal Tags - surgical excision
  4. High fiber diet, possibly with additional stool softeners, may help
  5. Local (Topical) Agents
    1. Vasconstrictors will shrink swollen tissues and often relieve pain (Preparation H®)
    2. Topical lidocaine ointment (5%)
    3. Topical glucocorticoids - should be avoided long term and in immunocompromised
  6. Non-Medical Hemorrhoid Treatment
    1. Rubber Band Ligation
    2. Infrared Coagulation
    3. Bipolar Electrocoagulation
    4. Low Voltage Direct Current
    5. Laser Therapy
  7. Surgical Hemorrhoidectomy
    1. Main problem is post-operative pain and consequent difficulty with defecation
    2. Metronidazole 500mg tid reduces post-operative pain on days 5-7 after procedure [3]
    3. Non-steroidal anti-inflammatory drugs are as effective as and safer than opiates

References

  1. Pfenninger JL and Zainea GG. 2001. Am Fam Phys. 64(1):77 abstract
  2. Helfand M, Marton KI, Zimmer-Gembeck JM, Sox HC Jr. 1997. JAMA. 277(1):44 abstract
  3. Carapeti EA, Kamm MA, McDonald PJ, Phillips RKS. 1998. Lancet. 351(9097):169 abstract