Hemorrhoids

Background

• Hemorrhoids (also known as piles) are a common anorectal condition in adults.
• External hemorrhoids are the abnormal engorgement or prolapse of anal cushions (submucosal blood vessels and fibrous tissue which normally assist with anal continence) which are located in the left lateral, right anterior, and right posterior portions of the anus.
  • External hemorrhoids are caused by increased straining or intra-abdominal pressure and are covered with squamous epithelium (anoderm).
  • External hemorrhoids originate distal to the dentate line (about 2 cm from the anal verge where the transitional mucosa joins the anoderm).
  • External hemorrhoids can be quite painful if they become thrombosed.
• Internal hemorrhoids are dilatations that originate from the inferior hemorrhoidal venous plexus above the dentate line, and are covered by columnar mucosa.
  • Internal hemorrhoids originate proximal to the dentate line regardless of whether they prolapse distally.
  • Internal hemorrhoids are painless because somatic pain fibers are not present above the dentate line.
  • Internal hemorrhoids are graded by degree of prolapse:
    • first-degree (grade 1) - bleeding without prolapse
    • second-degree (grade 2) - prolapse with straining (Valsalva), spontaneous reduction
    • third-degree (grade 3) - prolapse with straining, manual reduction needed
    • fourth-degree (grade 4) - chronically prolapsed, reduction impossible/ineffective

Evaluation

• Patients may attribute any anal symptoms to hemorrhoids, but may actually have other conditions, such as anal fissures, pruritis ani, or warts. It is important to make the correct diagnosis.
• Patients with portal hypertension may have hemorrhoids, but typically bleed from anorectal varices which are treated differently than hemorrhoids.
• Most common symptoms are bleeding, uncomfortable feeling of fullness or swelling at anus, and sensation of incomplete evacuation caused by prolapse.
• Hemorrhoidal bleeding is usually bright red blood at the end of defecation which is not mixed into the stool and may drip into the commode or appear on toilet paper.
• Thrombosis of an external hemorrhoid is characterized by severe sudden rectal pain with an exam demonstrating a purplish, engorged, tense, and tender submucosal perianal mass.
• Pain from a thrombosed external hemorrhoid usually peaks within 72 hours and resolves within 7-10 days.
• Other symptoms associated with hemorrhoids include anal itching, perineal irritation, and fecal soiling.
• Diagnosis is suggested by history of typical symptoms and must be confirmed with direct inspection of the anus or anoscopy. Digital rectal examination should be done to exclude masses.
• Anoscopy can be used as the least invasive method to visualize internal hemorrhoids, but findings hemorrhoids should not exclude investigation with sigmoidoscopy or colonoscopy for other potentially serious causes of hematochezia, especially if anemia is present.

Management

• For symptomatic hemorrhoids, advise first-line conservative therapy with increased insoluble fiber intake (for example, 30-35 g/day) and 6-8 glasses of water daily to modify stool form and firmness (Strong recommendation).
• Stool softeners or low-dose laxative therapy can be used if fiber and fluid provide insufficient improvement in stool form and firmness.
• Consider behavior modifications including avoidance of straining and prolonged time on the toilet, and good perianal hygiene which can be facilitated by warm Sitz baths once or twice a day.
• Comfort measures include topical treatments (local anesthetic ointment, mild astringents such as witch hazel, and corticosteroid cream).
• Consider phlebotonic dietary upplements (systemic agents that may work by strengthening blood vessel walls, increasing venous tone, or normalizing capillary permeability) to improve symptoms of hemorrhoids, including bleeding, pruritus, discharge, and leaking. Examples of phlebotonic dietary supplements include:
  • flavonoids, such as
    • bioflavonoids, hesperidin, diosmin, hydroxyethylrutoside
    • combination of diosmin plus hesperidin marketed as Daflon
  • troxerutin-carbazochrome (Toxivenol in United Kingdom and other countries)
  • dobesilate calcium (Doxium)
  • pine bark extract (Pycnogenol)
• For acute thrombosed external hemorrhoids, consider the following treatment options for symptom relief:
  • topical nitroglycerin
  • excision and evacuation of clot if the patient presents within 72 hours
• For internal hemorrhoids:
  • Offer rubber band ligation for symptomatic internal hemorrhoids unresponsive to conservative therapy (Strong recommendation).
  • Other less commonly employed procedures include sclerotherapy and photocoagulation.
• Reserve hemorrhoidectomy for patients with no response or inability to tolerate office procedures, large external hemorrhoids, or a combination of external and internal hemorrhoids with significant prolapse (Strong recommendation).