Hemorrhoids overview

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Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Hemorrhoids from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Hemorrhoids are varicosities or swelling and inflammation of veins in the rectum and anus. The rectum is the last part of the large intestine leading to the anus. The anus is the opening at the end of the digestive tract where bowel contents leave the body. External hemorrhoids are located under the skin around the anus. Internal hemorrhoids develop in the lower rectum. Internal hemorrhoids may protrude, or prolapse, through the anus. Most prolapsed hemorrhoids shrink back inside the rectum on their own. Severely prolapsed hemorrhoids may protrude permanently and require treatment.

Historical Perspective

Hemorrhoids were first discovered by ancient Egyptians more than 3700 years ago.

Classification

Hemorrhoids can be classified according to their site into external and internal hemorrhoids. Furthermore, internal hemorrhoids can be graded according to severity into 4 grades.

Pathophysiology

Hemorrhoids are developed due to combination of genetic predisposition (weak rectal veins) and following certain diet and defecation habits.

Causes

Hemorrhoids may be caused by caused by factors that increase the pressure in the rectal veins such as chronic cough, chronic constipation and straining.

Differentiating Hemorrhoids from other Diseases

Hemorrhoids should be differentiated from other diseases causing anal discomfort and pain with defaecation such as rectal cancer, anal fissure, anal abscess, anal fistula.

Epidemiology and Demographics

In the USA, the prevalence is about 4.4% while only about 500,000 patients in the U.S. are medically treated for massive hemorrhage, with 10 to 20% of them requiring surgeries. [1]

Risk Factors

Common risk factors in the development of hemorrhoids are excessive straining, sitting or standing for long periods of time, pregnancy, and Chronic constipation.

Screening

According to the USPSTF, screening for hemorrhoids is not recommended.

Natural History, Complications, and Prognosis

If left untreated, hemorrhoids may progress to develop strangulation, anemia or fecal incontinence. Common complications of hemorrhoids include secondary infection, thrombosis or strangulation. Prognosis is generally excellent and most cases respond to non surgical treatment. However, surgery gives the best prognosis with the least recurrence rate.

History and Symptoms

Symptoms of hemorrhoids include pain with defecation, haematochezia, and anal discharge.

Physical Examination

Patients with acute prolapsed or thrombosed hemorrhoids usually appear ill and in pain. Physical examination of patients with hemorrhoids is usually remarkable for protruding mass from the anus or palpable mass on digital rectal exam.

Laboratory Findings

There are no specific diagnostic lab findings associated with hemorrhoids. However, complete blood count may show anemia in case of chronic bleeding.

Imaging Findings

There are no x ray, MRI or ultrasound findings associated with hemorrhoids.

Other Diagnostic Studies

Anoscopy is mandatory to visualize internal hemorrhoids as they are not visible on inspection of the anal verge or palapable on performing digital rectal exam.

Medical Therapy

There is no medical treatment for hemorrhoids; the mainstay of therapy is local treatments such as warm sitz baths, using a bidet, extendable showerhead, cold compress, or topical analgesic (such as Nupercainal), can provide temporary relief.

Surgery

Surgery is not the first-line treatment option for patients with hemorrhoids. Surgical intervention is usually reserved for patients with either complicated or large hemorrhoids (beyond grade III)

Prevention

Eating a high-fiber diet can make stools softer and easier to pass, reducing the pressure on hemorrhoids caused by straining.

References

  1. Johanson JF, Sonnenberg A (1990). "The prevalence of hemorrhoids and chronic constipation. An epidemiologic study". Gastroenterology. 98 (2): 380–6. PMID 2295392.

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