Hemorrhoids

Hemorrhoids are not protruding “varicose veins”—they are distinct from the rectal varices of portal hypertension. Rather, hemorrhoids are downwardly displaced anal cushions, which are normal vascular tissue (sinusoids) that protect the anal canal during defecation. The supporting tissue of the cushions deteriorates over time and, with increased anal pressure (straining), leads to sliding, engorgement, bleeding, and prolapse of the cushions. Hemorrhoids are common, affecting up to 50% of the population.

Differential Diagnosis

• External hemorrhoids
  –Located below the pectinate line
  –Typically painful
• Internal hemorrhoids
  –Located above the pectinate line
  –Typically not painful, unless thrombosis
  occurs
• Pregnancy
  –Up to 35% of pregnant females will develop hemorrhoids around the time of delivery, with most cases occurring after a vaginal delivery and/or a prolonged labor
• Condylomata acuminatum (genital warts)
• Rectal prolapse
  –External protrusion of the rectum
  –Complete prolapse versus partial full thickness prolapse versus prolapse of mucosa only
  –Partial rectal prolapse or mucosa-alone rectal prolapse is typically concentric, thus can be differentiated from internal prolapsing hemorrhoids that tend to have separation between cushions and inflammation

• Rectal polyp
• Rectal or anal cancer
• Hypertrophied anal papilla (polypoid structure at pectinate line)
• External skin tag
  –Redundant fold of tissue along the external anal margin
• Perirectal abscess
• Anal fissure or fistula
• Rectal varices
  –Develop secondary to portal hypertension
• Rectal cavernous hemangioma

Workup and Diagnosis

• History: The most common presenting complaints are bright red bleeding following defecation (in toilet or on paper), itching, and prolapse of a hemorrhoid
  –Hemorrhoids are usually not painful unless thrombosed, ulcerated, or gangrenous
  –Sudden onset of excrutiating perirectal pain with palpable mass usually suggests acute thrombosis of a hemorrhoid
• Physical exam: Evaluate for prolapse by having patient strain (may place them on a toilet to facilitate)
  –First-degree hemorrhoid: No prolapse
  –Second-degree: Prolapse during defecation followed by spontaneous return to anal canal
  –Third-degree: Prolapsed but manually reducible
  –Fourth-degree: Constant, irreducible prolapse

• Anoscopy and proctosigmoidoscopy are used to evaluate symptoms and bleeding
• Full colonoscopy is indicated in all patients over 50 years old or if diagnosis is inconclusive
• Rectal manometry is indicated if the patient complains of incontinence
• Biopsy is necessary for any rectal polyp or palpable lesion

Treatment

• Treatment is initially conservative: High-fiber diet, stool softeners, appropriate anal hygiene, sitz baths, and topical steroids
• Surgical options include rubber band ligation of internal hemorrhoids or surgical resection for large refractory hemorrhoids
• Acute thrombosis of a hemorrhoid may require incision and drainage

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Anal symptoms

• Back to symptom: Anal symptoms: Introduction (review 274 causes)
• Next Book Extract About Anal symptoms: Rectal Pain (In a Page: Signs and Symptoms)
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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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