Hemorrhoids

Key points

• Hemorrhoids comprise the blood supply to the anus and distal rectum
• Features of hemorrhoids include bright red bleeding/staining of toilet paper, perianal irritation and itching, pain with external thrombosis or incarcerated prolapse (grade IV) of internal hemorrhoid, mucus or fecal staining of underclothes, prolapse, and skin tags
• In all patients with a complaint thought to be hemorrhoids, it is imperative to closely examine them to ensure that other, more urgent diagnoses are not the cause of complaint
• Many diagnoses may mimic hemorrhoid complaints, including infections, cancer, and inflammatory bowel disease
• Usual treatment includes sitz baths and laxatives
• Prolapsed irreducible internal hemorrhoids (grade IV) occasionally require urgent surgical intervention if manual reduction attempts fail
• Thrombosed external hemorrhoids when identified early in their course may be incised, which will decrease the duration of pain

Background

Description

• Hemorrhoids are present in all people and comprise the blood supply to the anus and distal rectum. Internal hemorrhoids are located above the dentate line, are covered by mucosa, and do not have sensory innervations; external hemorrhoids are located below the dentate line, are covered by squamous epithelium, and have sensory innervation
• The theory behind the development of hemorrhoidal disease is the 'sliding anal canal theory.' As the overlying mucosa and skin becomes redundant with maneuvers such as straining and constipation it prolapses into the anal canal and the dentate line prolapses. A small amount of prolapse results in bleeding or thrombosis; however, extensive prolapse is recognizable to the patient
• Hemorrhoids are normal features of anatomy; the presence of hemorrhoids without accompanying symptoms such as pain, pruritus, and bleeding does not necessitate treatment
• The usual course is self-limited. If significant prolapse develops, symptoms may become chronic
• Constipation from particularly hard stools and straining is frequently present
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Epidemiology

Prevalence

• Estimated at 50% of adults

Demographics

Age:

• More common with advancing age: peaks between ages 45 and 65 years
• Uncommon in infants; if present, an underlying cause such as venacaval or mesenteric obstruction,cirrhosis, or portal hypertension should be investigated

Gender:

• Equal incidence between male and female patients
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Race:

• Increased frequency among white patients

Genetics:

• May have a familial predisposition

Socioeconomic status

• Unclear
• Hemorrhoidal prevalence may be related to occupation rather than to social class
• Frequency of hemorrhoidal disease is higher among rural dwellers than urban dwellers in the U.S.

Causes and risk factors

Causes

Common causes:

• Hemorrhoidal bulging and distension into the lumen of the anal canal results from deterioration of connective tissue that supports hemorrhoids and occurs as a normal part of aging
• Conditions that increase intraabdominal pressure may accelerate deterioration of supporting connective tissue and prolapse of the anal canal, which is known as the sliding anal canal theory. Vessels become distended as they lose support

Serious causes:

• Any cause of portal hypertension such as cirrhosis can worsen hemorrhoidal vein pressure. A misconception is that rectal varices are a cause of hemorrhoidal disease. In patients with liver disease, varices may occur because of the dual blood supply to the rectum. When viewed endoscopically, rectal varices occur in the rectum and hemorrhoids are located in the anus. In such cases, treatment of the liver disease and portal system decompression is the primary goal

Risk factors

• Increased abdominal pressure as a result of ascites or pregnancy
• Diarrhea
• Pregnancy
• Childbirth is associated with thrombosed and prolapsed hemorrhoids
• Heavy lifting
• Prolonged sitting
• Conditions resulting in Valsalva maneuver such as chronic cough, straining related to constipation, or prostatism
• Anal intercourse

Associated disorders

• Anal fissures may occur simultaneously as the risk factors are similar
• Pruritis ani, or perianal itching, occurs as a result of perianal wetness from prolapse or difficult hygiene. Additionally, some hemorrhoidal creams and suppositories may worsen this symptom

Screening

Not applicable.

Primary prevention

Summary approach

Dietary modifications and high-fiber and high-fluid diets are the best measures for hemorrhoid prevention.

Preventive measures

• Patients should be advised to eat a diet high in fiber, low in fat, and to drink fluids liberally
• Patients should be advised to avoid anal intercourse or limit partners to minimize anorectal complications