What are hemorrhoids?
Hemorrhoids are inflamed, vascular structures normally found in the anal canal. First mentioned in the BCE Egyptian papyrus, they affect approximately 50 to 65% of the population. Hemorrhoids are not only blood vessels that are inflamed, but rather a cluster of blood vessels, smooth muscle (Treitz), and connective tissue all of which are lined by anal epithelium.
Based on their anatomic location, hemorrhoids are divided into internal and external hemorrhoids. This classification is dependent on the location of hemorrhoids with regards to the dentate line.
Hemorrhoids are one of the most common anal pathologies, and most anorectal pathologies are often misdiagnosed as hemorrhoids due to overlapping symptoms. Furthermore, many patients feel embarrassed and do not visit their doctor on time with their complaints
It is important to note that hemorrhoids refers to both the normal vascular structures found in the anal canal and the inflammation of these structures. However, in this article, hemorrhoids refers to inflamed, pathologic structures found in the anal canal.
What causes Hemorrhoids?
Exact etiology of hemorrhoids is not known. Some credit the development of hemorrhoids to the absence of valves in hemorrhoidal veins, but no concrete evidence can be provided for this theory. Several other risk factors are associated with the inflammation of hemorrhoids. An exact causal link has yet to be discovered.
- Irregular bowel movements (Constipation and Diarrhea) and Straining: These have been thought to cause hemorrhoids for a long time, however, studies exist to prove both sides of the argument. Straining and sitting on the toilet bowl for a long time is associated with increased pressure, which decreases venous return and leads to enlargement of hemorrhoidal vasculature.
- Aging: Studies have found that over time, the supporting structures of the anal canal weaken resulting in prolapse and hemorrhoids.
- Pregnancy: It is hypothesized to cause hemorrhoids through either high pressure or hormonal changes.
- Portal hypertension, Ascites, Varices: Portal hypertension results in ascites which can increase the intra abdominal pressure, and anorectal varices amongst others which can lead to rectal bleeding.
- Low fiber diets
- Familial association: It can be easily explained with shared habits that can result in hemorrhoids or the same diet in a family that predisposes an individual to hemorrhoids.
- Higher socioeconomic status: According to a study conducted in 2019 in India, approximately 37.2% of affected individuals were of higher socioeconomic status
- Chronic diarrhea
- Colorectal cancer
- Elevated anal resting pressure
- Spinal cord injury
- Colorectal surgery, resulting in iatrogenic damage to rectal muscle.
- Episiotomy during childbirth
- Anal intercourse
- Inflammatory bowel disease: Crohn disease
Types of Hemorrhoids
As mentioned above, hemorrhoids are classified into two types based on their location:
- Internal Hemorrhoids: They are covered by columnar epithelium and occur above the dentate or pectinate line. Since internal hemorrhoids are innervated by somatic sensory nerves and the columnar epithelium lacks pain receptors, this type is not associated with any pain. However, they can prolapse and bleed which may cause perianal irritation and pain, especially through prolapse-associated spasms.
- External Hemorrhoids: They are covered by anoderm/ectoderm and are distally covered by skin. They occur below the dentate/pectinate line. This type is more common and the more painful type. It can cause difficulty sitting, itching along with pain.
What are the symptoms of hemorrhoids?
Approximately 40% of affected individuals present with no symptoms. However, the rest may present with symptoms depending on the type. Also, most patients present in the advanced state, due to embarrassment associated with hemorrhoids
- Rectal bleeding is the most common presenting symptom.
- Anal pruritus is common in both types if advanced
- Pain is a common feature of external, but internal hemorrhoids only cause pain when prolapsed and thrombosed
- Skin tags may be left by external hemorrhoids after they resolve.
How are hemorrhoids diagnosed?
Since rectal bleeding is the most common presenting symptom, the physician must ask for the onset, type, and quality of the bleeding. Normally, patients present with bright red pain that streaks the toilet paper or drips. A detailed history including questions about the risk factors, habits, and pain & bleeding onset, and type.
Visual exam to look for any skin tags, prolapse, or thrombosed structures may be performed. For this, a digital rectal exam can be done, which may be useful to detect rectal cancers, polyps, masses, and hemorrhoids.
For internal hemorrhoids, however, anoscopy needs to be done to confirm the diagnosis. Anoscopy is the use of an anoscope, a rigid tube, to visualize the anal canal. Three types of anoscopes are available; slotted, non-slotted, and beveled. The anoscope is inserted into the anus using an obturator, which is then removed to visualize the canal.
A non-slotted scope provides a 360 degrees view but since it can cover the hemorrhoids, it is not the best choice to view hemorrhoids.
Slotted and beveled scopes allow better and direct view of the hemorrhoids and are preferred over non-slotted anoscopes. Among these two, beveled scopes are preferred since they can rotate and allow a full view of the anal canal and its pathologies. Rotation of a slotted scope will cause pain to the patients.
This modality does not provide a clear view of the hemorrhoids and the anal canal since the scope itself is in the anal canal, obstructing the view. It is not of much use for the diagnosis of hemorrhoids.
For internal hemorrhoids, however, anoscopy needs to be done to confirm the diagnosis. And since internal hemorrhoids have a risk of prolapse, they are graded on the degree of prolapse. This grading allows physicians to choose the appropriate treatment modality. The grading is as follows;
- Grade I: Visible blood vessels, no prolapse of hemorrhoidal cushions
- Grade II: Prolapse, will be spontaneously reduced.
- Grade III: Prolapse that can be manually reduced.
- Grade IV: Prolapsed cushions that cannot be manually reduced.
Differential Diagnosis of hemorrhoids
Anorectal pathologies have overlapping, similar symptoms that make an accurate diagnosis difficult. The following diseases need to be considered and excluded before confirming the diagnosis:
- Anal fissures
- Colorectal cancer
- Rectal varices
- Rectal Prolapse
How are hemorrhoids treated?
The treatment of hemorrhoids can be divided into three types: Conservative therapy, office procedures, and surgery.
This intervention involves warm baths (2x-3x/week), proper anal hygiene education, high fiber diet, stool softeners and laxatives, and proper fluid intake. This is the choice of treatment for grade I internal and non thrombosed external hemorrhoids. It is also important to inform the patient of the risk involved with prolonged sitting on the toilet. They need to change their toilet habits.
- Rubber band ligation: It is the treatment of choice for grade I to III of internal hemorrhoids.
- Sclerotherapy: It causes the hemorrhoidal vessels to collapse and decreases the overall size of the hemorrhoidal cushion.
- Electrocautery, infrared radiation, laser surgery, or cryosurgery: These are cauterization methods, beneficial for use in grade I and II of internal hemorrhoids. However, they can also be used for grades III and IV, but they will reoccur. These procedures are performed routinely, however this method of treatment is strictly contraindicated in AIDS, pregnancy, anal fissure, and rectal prolapse patients, and in patients with immunodeficiency disorders.
Many surgical options are available for the treatment of hemorrhoids. They are all associated with risks of bleeding, urinary retention, infection, and anal strictures.
- Surgical hemorrhoidectomy: It is the most effective surgery and is reserved for severe cases of hemorrhoids
- Stapled hemorrhoid surgery: This intervention can be performed in outpatient clinics under local anesthesia. It is used for prolapsing hemorrhoids and involves stapling of the hemorrhoidal cushions back to their anatomic location
- Hemorrhoidal artery ligation
- Doppler-guided transanal hemorrhoidal dearterialization
The last two choices have been showing promising results, with more studies being conducted. Both of them follow the concept of decreasing blood flow to hemorrhoidal cushions, resulting in decreased size.
Hemorrhoids are part of normal human anatomy. Inflammation, engorgement, prolapse, or thrombosis of them can be painful and if not diagnosed on time, it can cause further complications. They are nothing to be embarrassed about and everyone who suspects themselves to be affected by this should visit a doctor on time. A timely diagnosis can prevent complications. Furthermore, complying with the conservative treatment can prove beneficial and everyone should follow the recommendations strictly.