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Hemorrhoids
Juan Qiu, MD, PhD
image BASICS
DESCRIPTION
  • Varicosities of the hemorrhoidal venous plexus
  • External hemorrhoids
    • Located below the dentate line (painful)
    • Covered by squamous epithelium
  • Internal hemorrhoids
    • Located above the dentate line (painless)
  • Both types of hemorrhoids often coexist.
  • Classification of internal hemorrhoids (1,2,3)
    • 1st-degree: Hemorrhoids do not prolapse.
    • 2nd-degree: prolapse through the anus on straining but reduce spontaneously
    • 3rd-degree: protrude and require digital reduction
    • 4th-degree: cannot be reduced
  • Hemorrhoids often progress from itching, bleeding stage to protrusion with easy reduction; then difficult reduction; and finally, rectal prolapse. Thrombosis may occur at any protrusion stage. External hemorrhoids cause pain; internal hemorrhoids generally do not (2,3).
Geriatric Considerations
Hemorrhoids are more common in elderly, as is rectal prolapse.
Pediatric Considerations
  • Uncommon in infants and children; when discovered, look for underlying cause (e.g., vena caval or mesenteric obstruction, cirrhosis, portal hypertension [HTN]).
  • Occasionally, as in adults, hemorrhoids may result from chronic constipation, fecal impaction, and straining at stool. Surgery is rarely required in children.
Pregnancy Considerations
  • Common in pregnancy
  • Usually resolves after pregnancy
  • No treatment required, unless extremely painful.
EPIDEMIOLOGY
  • Predominant age: adults; peak from 45 to 65 years
  • Predominant sex: male = female
Incidence
Common
Prevalence
˜4-5% in general population in the United States
ETIOLOGY AND PATHOPHYSIOLOGY
  • There are three primary hemorrhoidal cushions typically located in left lateral, right anterior, and right posterior positions. Hemorrhoidal cushions augment anal closure pressure and protect the anal sphincter during stool passage. During Valsalva, intra-abdominal pressure increases raising pressure within the hemorrhoidal cushions helping to preserve anal closure. Mechanisms implicated in symptomatic hemorrhoidal disease include the following:
    • Dilated veins of hemorrhoidal plexus
    • Tight internal anal sphincter
    • Abnormal distention of the arteriovenous anastomosis
    • Prolapse of the cushions and the surrounding connective tissues
Genetics
No known genetic pattern
RISK FACTORS
  • Pregnancy
  • Pelvic space-occupying lesions
  • Liver disease; portal HTN
  • Constipation
  • Occupations that require prolonged sitting
  • Loss of perianal muscle tone due to old age, rectal surgery, birth trauma/episiotomy, anal intercourse
  • Obesity
  • Chronic diarrhea
GENERAL PREVENTION
  • Avoid constipation by consuming high-fiber diet (>30 g/day) and ensuring proper hydration.
  • Maintain appropriate weight.
  • Avoid prolonged sitting or straining on the toilet.
COMMONLY ASSOCIATED CONDITIONS
  • Liver disease; portal HTN
  • Pregnancy
  • Constipation
image DIAGNOSIS
Diagnosis is typically straightforward through history and inspection of the perineum, rectal exam, and anoscopy.
PHYSICAL EXAM
  • Anorectal exam including anoscopy (2,3)
  • Inspection following straining at stool
  • For protruding hemorrhoids: mass, more prominent bleeding. If not reducible, increased risk of strangulation and/or thrombosis with acute pain
  • Abdominal exam to exclude mass
  • Peripheral stigmata of cirrhosis and portal hypertension (caput, telangiectasias, palmar erythema)
DIFFERENTIAL DIAGNOSIS
  • Rectal or anal neoplasia
  • Condyloma
  • Skin tag
  • Inflammatory bowel disease
  • Anal fistula, fissure, or abscess
DIAGNOSTIC TESTS & INTERPRETATION
Diagnostic Procedures/Other
Sigmoidoscopy or colonoscopy depending on risk factors for malignancy in patients with rectal bleeding (3)[A]
image TREATMENT
Prevention
  • Fiber supplements
  • Stool softeners
GENERAL MEASURES
  • Hemorrhoids are a recurrent disease, even after surgical excision. Preventive measures should be continued indefinitely.
  • For mild symptoms or prevention (3)[A]
    • Avoid prolonged sitting during bowel movements.
    • Avoid straining.
    • Avoid constipation by eating a high-fiber diet or by taking fiber supplements; if necessary, take regular stool softeners.
    • Regular exercise
  • For pain, Sitz baths warm water or hypertonic Epsom salts (1 cup per 2 quarts of water)
  • Pruritus or mild discomfort after stooling responds well to topical hydrocortisone ointment, anesthetic ointments or sprays, and warm Sitz baths.
  • Constipation relief, anal hygiene, local ointments, and Sitz baths are effective through the stage of easy reduction (stage 2). More severe stages often require ligation or surgery (3)[A].
MEDICATION
First Line
  • Dietary modification with adequate fluid (generally ≥2 L water/day) and fiber (≥30 g/day) is the primary first-line, nonoperative therapy for symptomatic hemorrhoids (3)[A].
  • Pain
    • Hydrocortisone ointment (0.5-1%)
    • Analgesic sprays or ointments: benzocaine and dibucaine (Nupercainal). Use sprays with caution, as they may contain alcohol that can cause burning sensation when applied.
  • Pruritus: hydrocortisone (Anusol-HC, Cortifoam) ointment
  • Bleeding
    • Astringent suppositories (Preparation H)
    • Hydrocortisone (Anusol-HC, Cortifoam) ointment
Second Line
Treatment for special cases
  • Thrombosed external hemorrhoids: common complication of hemorrhoidal disease. With conservative treatment, the thrombus will be absorbed over the course of weeks, and pain improves within 2 to 3 days (1,2,3)[A].
  • With severe acute pain, prompt excision should be performed under local anesthetics and the wound left open without packing. Use Sitz baths, topical anesthetics, and mild pain relievers for the first 7 to 10 days after excision (1,2,3)[A].
  • Strangulated hemorrhoid: from irreducible 3rd- or 4th-degree hemorrhoid. If untreated, it can progress to ulceration and thrombosis. Treatment requires urgent or emergent hemorrhoidectomy.
  • Acute hemorrhoidal bleeding associated with portal HTN can be life-threatening. Treatment should be suture of the bleeding site with incorporation of the mucosa, submucosa, and internal sphincter. Coagulopathy should be corrected.
P.459

SURGERY/OTHER PROCEDURES
  • Indications: failure of medical and nonoperative therapy, symptomatic stage 3 or stage 4 symptoms in presence of a concomitant anorectal condition requiring surgery, or patient preference (1,2,3)[A]
  • Incision of thrombosed hemorrhoid: for severe pain
  • Severe protruding hemorrhoids
    • Rubber band ligation (internal hemorrhoids only) (1,2,3)[A]
    • Sclerotherapy: for symptomatic prolapsed stage I or II hemorrhoids; care must be taken not to inject near periprostatic parasympathetic nerves. Not for advanced disease or if evidence of infection, inflammation, and ulceration is present
      • Cryotherapy is no longer recommended due to high rate of complications.
    • Prolapsed rectum
      • Requires surgical correction
    • Surgical resection
      • Gold standard: Conventional hemorrhoidectomy should be considered for grade III hemorrhoids not responding to banding, mixed internal and external, grade IV hemorrhoids, or when complicated by fissures, fistula, or extensive skin tags (1,2,3)[A].
  • Newer techniques reduce surgical time, early postoperative pain, urinary retention, and time to return to normal activity.
    • Transanal hemorrhoidal dearterialization (THD): fewer complications and can be used in cases of recurrent diseases (2,3)[A],(4)[B]
    • Stapled hemorrhoidopexy: less painful than traditional surgery but higher incidence of skin tags and recurrent prolapse (2)[A],(4)[B]
    • LigaSure hemorrhoidectomy: reduces operating time, is superior in patient tolerance, and is equally effective as conventional hemorrhoidectomy in long-term symptom control (5,6)[B],(7,8)[A]
COMPLEMENTARY & ALTERNATIVE MEDICINE
Aloe vera cream on the surgical site after hemorrhoidectomy reduces postoperative pain and decreases healing time and analgesic requirements.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Encourage physical fitness, weight management, and dietary compliance.
  • Avoid prolonged sitting and straining on the toilet.
Patient Monitoring
As needed, depending on treatment
DIET
High-fiber with a target of 30 g of insoluble fiber/day through sources such as wheat bran cereals, oatmeal, peanuts, artichokes, beans, corn, peas, spinach, potatoes, apples, apricots, blackberries, raspberries, prunes, pears, bananas; adequate fluids (6 to 8 glasses of water/day); avoid excessive caffeine.
PATIENT EDUCATION
High-fiber diet: Today's Dietitian Top Fiber-Rich Foods List. http://www.todaysdietitian.com/newarchives/063008p28.shtml
PROGNOSIS
  • Spontaneous resolution
  • Recurrence
REFERENCES
1. Klein JW. Common anal problems. Med Clin North Am. 2014;98(3):609-623.
2. Hall JF. Modern management of hemorrhoidal disease. Gastroenterol Clin North Am. 2013;42(4):759-772.
3. Ganz RA. The evaluation and treatment of hemorrhoids: a guide for the gastroenterologist. Clin Gastroenterol Hepatol. 2013:11(6):593-603.
4. Ratto C. THD Doppler procedure for hemorrhoids: the surgical technique. Tech Coloproctol. 2014:18(3):291-298.
5. Michalik M, Pawlak M, Bobowicz M, et al. Long-term outcomes of stapled hemorrhoidopexy. Wideochir Inne Tech Maloinwazyjne. 2014;9(1):18-23.
6. Chen CW, Lai CW, Chang YJ, et al. Results of 666 consecutive patients treated with LigaSure hemorrhoidectomy for symptomatic prolapsed hemorrhoids with a minimum follow-up of 2 years. Surgery. 2013;153(2):211-218.
7. Nienhuijs S, de Hingh I. Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic hemorrhoids. Cochrane Database Syst Rev. 2009;(1):CD006761.
8. Xu L, Chen H, Lin G, et al. Ligasure versus Ferguson hemorrhoidectomy in the treatment of hemorrhoids: a meta-analysis of randomized control trials. Surg Laparosc Endosc Percutan Tech. 2015;25(2):106-110.
Additional Reading
&NA;
  • Reese GE, von Roon AC, Tekkis PP. Haemorrhoids. BMJ Clin Evid. 2009;2009:0415.
  • Rivadeneira DE, Steele SR, Ternent C, et al. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum. 2011;54(9):1059-1064.
See Also
&NA;
Colorectal Cancer; Portal Hypertension
Codes
&NA;
ICD10
  • K64.9 Unspecified hemorrhoids
  • K64.0 First degree hemorrhoids
  • K64.1 Second degree hemorrhoids
Clinical Pearls
&NA;
  • Hemorrhoids are a very common clinical condition. Internal hemorrhoids are painless. External hemorrhoids are typically painful.
  • Anal hygiene and symptomatic pain relief are the treatments of choice for stage 1 and 2 hemorrhoids. Sitz baths with warm water or hypertonic Epsom salts (1 cup per 2 quarts of water) are effective for pain relief.
  • All patients should be encouraged to eat a high-fiber diet with 30 g of insoluble fiber per day.
  • More advanced hemorrhoidal disease requires intervention with ligation or surgery.