Hemorrhoid

Hemorrhoid Hemorrhoids Classification and external resources Schematic demonstrating the anatomy of hemorrhoids. ICD-10 I84. ICD-9 455 DiseasesDB 10036 MedlinePlus 000292 eMedicine med/2821 emerg/242 MeSH D006484 Hemorrhoids (US English) or haemorrhoids (Commonwealth English), also known as piles and "Tum-Bum" are part of the normal human anatomy of the anal canal. They become pathological when swollen or inflamed. In their physiological state they act as cushions composed of arterio-venous channels and connective tissue that aid the passage of stool. The symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless rectal bleeding while external hemorrhoids present with pain in the area of the anus. Recommended treatment consists of increasing fiber intake, oral fluids to maintain hydration, NSAID analgesics, sitz baths, and rest. Surgery is reserved for those who fail to improve following these measures. Contents • 1 Signs and symptoms • 2 Causes • 3 Pathophysiology • 4 Prevention • 5 Diagnosis o 5.1 Differential • 6 Treatments o 6.1 Procedures • 7 Epidemiology • 8 Notable cases • 9 References Signs and symptoms Classical appearance of an external hemorrhoid. Hemorrhoids are usually benign. In most cases, symptoms will resolve within a few days. External hemorrhoids are painful while internal hemorrhoids usually are not. The most common symptom of internal hemorrhoids is bright red blood covering the stool, a condition known as hematochezia, on toilet paper, or in the toilet bowl. They may protrude through the anus. Symptoms of external hemorrhoids include painful swelling or lump around the anus. Causes A number of factors may lead to the formations of hemorrhoids including irregular bowel habits (constipation or diarrhea), exercise, gravity, nutrition (low-fiber diet), increased intra-abdominal pressure (prolonged straining), pregnancy, genetics, absence of valves within the hemorrhoidal veins, and aging. Other factors that can increase the rectal vein pressure resulting in hemorrhoids include obesity, and sitting for long periods of time. During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. Delivery also leads to increase intra abdominal pressures. Surgical treatment is rarely needed as symptoms usually resolve post delivery. Pathophysiology This section requires expansion. Hemorrhoid cushions are a part of normal human anatomy and only become a pathological disease when they experience abnormal changes. There are three cushions present in the normal anal canal. Prevention The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass. Spending less time attempting to defecate and avoiding reading while on the toilet have been recommended. Diagnosis Endoscopic image of internal hemorrhoids seen on retroflexion of the flexible sigmoidoscope at the ano-rectal junction A visual examination of the anus and surrounding area may be able to diagnose external or prolapsed hemorrhoids. A rectal exam may be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses. This examination may not be possible without appropriate sedation due to pain. Visual confirmation of internal hemorrhoids is via anoscopy. This device is basically a hollow tube with a light attached at one end that allows one to see the internal hemorrhoids, as well possible polyps in the rectum. Differential Many anorectal problems, including fissures, fistulae, abscesses, colorectal cancer, rectal varices and itching,diverticulosis,polyps have similar symptoms and may be incorrectly referred to as hemorrhoids. Treatments Conservative treatment typically consists of increasing dietary fiber, oral fluids to maintain hydration, non-steroidal anti-inflammatory drugs (NSAID)s, sitz baths, and rest. Increased fiber intake has been shown to improve outcomes and may be achieved by dietary alterations or the consumption of fibre supplements . While many topical agents and suppositories are available for the treatment of hemorrhoids there is little evidence to support their use. Preparation H may improve local symptoms but does not improve the underlying disorder and long term use is discouraged due to local irritation of the skin. Procedures • Rubber band ligation is a procedure in which elastic bands are applied onto an internal hemorrhoid at least 1 cm above the dentate line to cut off its blood supply. Within 5–7 days, the withered hemorrhoid falls off. If the band is placed too close to the dentate line intense pain results immediately afterwards.Cure rate has been found to be about 87%. • Sclerotherapy involves the injection of a sclerosing agent (such as phenol) into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate at four years is 70%. • A number of cautery methods have been shown to be effective for hemorrhoids. This can be done using electrocautery, infrared radiation, or cryosurgery. A number of surgical techniques may be used if conservative medical management fails. All are associated with some degree of complications including urinary retention, due to the close proximity to the rectum of the nerves that supply the bladder, bleeding, infection, and anal strictures. • Hemorrhoidectomy is a surgical excision of the hemorrhoid used primary only in severe cases. It is associated with significant post operative pain and usually requires 2–4 weeks for recovery. • Doppler guided transanal hemorrhoidal dearterialization is a minimally invasive treatment. Consiosts in ligation of the six branches of the superior rectal artery, the cause of arterial hyperinflux and therefore of swelling and bleeding of the haemorrhoidal plexus, which are localised and ligated high in the rectal canal. It is not at all invasive as no tissue is cut or removed in the anal-rectal canal. Given its non-invasiveness, no significant complications can occur. The method can be repeated and does not prevent other operations on the anal-rectal channel from being carried out as full restitutio ad integrum occurs within three months from the operation, that is, the anal-rectal canal regains its normal anatomy as though it had never been operated on at all. • Stapled hemorrhoidectomy is a procedure that involves resection of soft tissue proximal to the dentate line, disrupting the blood flow to the hemorrhoids. It is generally less painful than complete removal of hemorrhoids and was associated with faster healing compare to a hemorrhoidectomy. Epidemiology Symptomatic hemorrhoids affect at least 50% of the American population at some time during their lives, with around 5% of the population suffering at any given time, and both sexes experiencing the same incidence of the condition. They are more common in Caucasians