Brief Summary of Hemorrhoids

Hemorrhoidal varices are part of the normal anatomy. Dilation and enlargement of the superior plexus of the superior hemorrhoidal veins located above the dentate line produce internal hemorrhoids. Enlargement of the plexus of the inferior hemorrhoidal veins located below the dentate line produces external hemorrhoids.External hemorrhoids may protrude from the rectum. Hemorrhoids occur in both sexes. Incidence is generally highest between ages 20 and 50.

Causes
Hemorrhoids result from activities that increase intravenous pressure, resulting in distention and engorgement. 

Predisposing factors include 

• prolonged sitting, 
• straining at defecation,
•  constipation,
• low-fiber diet, 
• pregnancy, and 
• obesity.

Other factors include hepatic disease, such as cirrhosis, amebic abscesses, or hepatitis; alcoholism; and anorectal infections.

Signs and symptoms

Internal hemorrhoids may produce no symptoms. They characteristically cause painless, intermittent bleeding during defecation. Bright red blood appears in stools or on toilet paper because of injury to the fragile mucosa covering the hemorrhoid.
When hemorrhoids prolapse, they’re usually painless and spontaneously return to the anal canal after defecation.

External hemorrhoids cause constant discomfort and prolapse in response to any increase in intra-abdominal pressure. They can be manually reduced. Thrombosis of external hemorrhoids produces sudden rectal pain and a large, firm, subcutaneous lump that the patient can feel.
Hemorrhoids seldom cause severe bleeding leading to anemia.

Diagnosis
Physical examination confirms external hemorrhoids. Anoscopy or proctoscopy provides for visual examination of internal hemorrhoids.

Treatment
Treatment depends on the type and severity of the hemorrhoids.

Nonsurgical treatments
Nonsurgical treatments include measures to control pain, combat swelling and congestion, and regulate bowel habits. 

Patients can relieve constipation by consuming a high-fiber diet and increasing fluid intake by drinking eight to ten 8-oz glasses of water per day or by using bulking agents such as psyllium.

Venous congestion can be prevented by avoiding prolonged sitting on the toilet; local swelling and pain can be decreased with local anesthetic agents (lotions, creams, or suppositories) or astringents. 

Hydrocortisone suppositories may be used for edematous, prolapsed hemorrhoids in combination with warm sitz baths.

Hemorrhoids may be treated with injection sclerotherapy and rubber band ligation. Infrared photocoagulation bipolar diathermy may be used to affix the mucosa to the underlying muscle.

Hemorrhoidectomy
Hemorrhoidectomy is performed for patients with severe bleeding and those with thrombosed hemorrhoids. This procedure is contraindicated in patients with blood dyscrasias (acute leukemia, aplastic anemia, or hemophilia) or gastric cancer and during the first trimester of pregnancy.