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BASICS

Description

  • Varicosities of the hemorrhoidal venous plexus.
  • External hemorrhoids: below dentate line, somatic innervation → painful.
  • Internal hemorrhoids: above dentate line, visceral innervation → painless.
  • Internal hemorrhoids classification:
  • Grade I: bulging without prolapse
  • Grade II: prolapse with straining, spontaneously reduces
  • Grade III: prolapse with straining, requires manual reduction
  • Grade IV: irreducible prolapse

Epidemiology

  • Common, peak age 45–65 years.
  • Equal sex distribution.
  • 4–5% prevalence; 39% detected on screening colonoscopy.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Exact mechanism unknown.
  • Hemorrhoidal cushions aid anal closure and sphincter protection.
  • Valsalva increases intra-abdominal pressure → dilated veins.
  • Pathogenic factors: venous dilation, tight internal sphincter, abnormal arteriovenous anastomoses, prolapse of cushions/connective tissue.

Risk Factors

  • Pregnancy
  • Pelvic masses
  • Liver disease, portal hypertension
  • Chronic constipation/straining
  • Prolonged sitting
  • Loss of perianal muscle tone (age, trauma, surgery)
  • Obesity
  • Chronic diarrhea

DIAGNOSIS

History

  • Symptoms: bleeding (bright red), pruritus, perianal discomfort, soiling.
  • Thrombosed external hemorrhoids: acute painful mass.
  • Assess bowel habits, diet, systemic symptoms, and relevant history.

Physical Exam

  • Inspection with Valsalva in left lateral, lithotomy, or knee-chest position.
  • Digital rectal exam: assess sphincter tone, tenderness.
  • Anoscopy: visualize internal hemorrhoids as purple masses.
  • Evaluate for other anorectal pathology.
  • Abdominal exam for masses.
  • Look for cirrhosis stigmata if portal HTN suspected.

Differential Diagnosis

  • Anal or rectal cancer
  • Condyloma, skin tags
  • IBD
  • Anal fistula, fissure, abscess
  • Rectal polyp or prolapse

DIAGNOSTIC TESTS

  • Labs generally not needed unless anemia suspected.
  • Colonoscopy or sigmoidoscopy if bleeding or malignancy risk.
  • Anoscopy important for internal hemorrhoids.

TREATMENT

Prevention

  • High-fiber diet (>30 g/day), hydration.
  • Avoid prolonged sitting/straining.

General Measures

  • Conservative therapy effective for mild symptoms.
  • Sitz baths, anal hygiene.
  • Avoid constipation, straining.

Medications

  • First line:
  • Dietary fiber and fluid intake
  • Stool softeners or bulk-forming laxatives
  • Topical anesthetics (benzocaine, lidocaine, pramoxine) for symptomatic relief
  • Corticosteroid ointments for short-term use
  • Astringents (witch hazel)

  • Vasoconstrictors (phenylephrine)

  • Second line:

  • Acute thrombosed external hemorrhoids: incision and clot evacuation within 72 hours.
  • Strangulated hemorrhoids: urgent hemorrhoidectomy.

Procedures and Surgery

  • Rubber band ligation (RBL): most effective office treatment for internal hemorrhoids; avoid anticoagulants.
  • Infrared photocoagulation: necrosis of hemorrhoid with less pain, higher recurrence than RBL.
  • Sclerotherapy: injection causing thrombosis, useful in bleeding risk patients.
  • Cryotherapy: no longer recommended.
  • Surgery for grade III/IV or failed conservative therapy:
  • Conventional hemorrhoidectomy (open or closed)
  • Doppler-guided hemorrhoidal artery ligation (HAL)
  • Stapled hemorrhoidopexy
  • LigaSure hemorrhoidectomy
  • Laser treatment (less pain and bleeding)

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Oral bioflavonoids reduce bleeding, pruritus, recurrence.
  • Topical nifedipine for thrombosed hemorrhoid pain.
  • Topical nitroglycerin reduces sphincter spasm (headache side effect).
  • Botulinum toxin for anal sphincter spasm relief.
  • Aloe vera cream post-hemorrhoidectomy reduces pain and healing time.

ONGOING CARE

  • Encourage fiber intake, hydration, exercise, weight control.
  • Avoid prolonged sitting and straining.

Diet

  • High-fiber foods: wheat bran, oatmeal, fruits, vegetables.
  • Adequate fluids.
  • Limit caffeine.

Patient Education

  • Increase dietary fiber gradually.
  • Refer to https://familydoctor.org/fiber-how-to-increase-the-amount-in-your-diet/

PROGNOSIS

  • Many cases resolve spontaneously.
  • Recurrence common.
  • Complications: thrombosis, ulceration, incontinence, pelvic sepsis post-surgery.

CLINICAL PEARLS

  • Internal hemorrhoids are usually painless; external hemorrhoids typically painful.
  • Conservative management successful in many cases.
  • Fiber intake (25–35 g/day) essential.
  • Surgery or ligation needed for advanced disease.

REFERENCES

  1. Mott T, Latimer K, Edwards C. Hemorrhoids: diagnosis and treatment options. Am Fam Physician. 2018;97(3):172-179.
  2. Davis BR, Lee-Kong SA, Migaly J, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of hemorrhoids. Dis Colon Rectum. 2018;61(3):284-292.
  3. Aibuedefe B, Kling SM, Philp MM, et al. An update on surgical treatment of hemorrhoidal disease: a systematic review and meta-analysis. Int J Colorectal Dis. 2021;36(9):2041-2049.