Hemorrhoids

Abnormally large or symptomatic conglomerates of blood vessels, supporting tissues, and overlying mucous membrane or anorectal skin.

A hemorrhoid is a varicose vein of the anorectal junction. An internal hemorrhoid is the part of the varicosity above the dentate line (involving rectal mucosa); an external hemorrhoid is the distal part, which is covered with anorectal skin (anoderm). Prolapsed internal hemorrhoids extend into the anal canal or through the anus. A thrombosed external hemorrhoid is a localized clot that forms in the vein of an external hemorrhoid or arises from a ruptured hemorrhoidal blood vessel. Combined hemorrhoids include internal and external hemorrhoids.

Hemorrhoids develop because the vena cava and iliac veins have no valves; consequently, erect posture, heavy lifting, and straining can distend the veins. Rarely, hemorrhoids indicate a lesion higher in the colorectum (eg, a left colon or rectal malignancy) or of portal hypertension secondary to intrinsic liver disease.

Symptoms and Signs

Internal hemorrhoids may be asymptomatic in the early stages, but later, they tend to bleed. The bleeding is usually minimal, appearing as bright red blood on stool or on toilet paper. Rarely, significant bleeding occurs: If blood is retained above the sphincter, a large amount can be expelled at one time. Continued blood loss, even in small increments, can lead to anemia. External hemorrhoids may also bleed. Pain occurs only with prolapsed internal hemorrhoids and thrombosed external hemorrhoids (which produce sudden, severe perianal pain). Thrombosed external hemorrhoids may also cause itching.

Diagnosis and Treatment

External hemorrhoids can be diagnosed by inspection and nearly always indicate the presence of internal hemorrhoids. Diagnosis of internal hemorrhoids requires anoscopy, because hemorrhoids are soft and cannot be reliably detected digitally. A thrombosed external hemorrhoid appears as a tense, blue subcutaneous mass. For elderly patients with rectal bleeding, the physical examination should be supplemented with either proctosigmoidoscopy plus a barium enema or total colonoscopy.

For mild hemorrhoids, treatment consists of a soft diet and a bulk producer (eg, psyllium hydrophilic mucilloid). Heavy lifting and straining at stool should be avoided. Sitz baths and suppositories or ointments containing benzocaine or another local anesthetic can relieve symptoms.

For mildly prolapsed or bleeding internal hemorrhoids, rubber bands can be applied snugly around the base of each major hemorrhoid during one or more office visits. The bands should be positioned above the anal canal, or great pain results. Posttreatment discomfort is moderate, and long-term results are good. Rarely, band ligation is complicated by severe perianal sepsis; early symptoms include prolonged pain, fever, and urinary retention.

Sclerotherapy (eg, with quinine urea hydrochloride 5%) has good early results, but later, secondary hemorrhoids tend to develop. Hemorrhoidectomy of secondary hemorrhoids is more difficult.

Cryosurgery and laser therapy are less popular alternatives because the amount of tissue removed is small, thus healing and symptom relief are delayed.

For combined hemorrhoids or internal hemorrhoids with major prolapse, hemorrhoidectomy is the most effective treatment. It can relieve symptoms immediately and has excellent long-term results.

For a thrombosed external hemorrhoid, subcutaneous injection of a local anesthetic and evacuation provide immediate relief. A small section of skin should be excised to allow adequate drainage in case of further bleeding. Some small clots resolve without much discomfort, but large ones, if not evacuated, are slow to improve and are painful for many days. Warm sitz baths and analgesics are beneficial.