Hemorrhoid Overview

Hemorrhoids are enlarged veins located in the lower part of the rectum and the anus. The veins become swollen due to increased pressure within them, usually from constipation or profuse diarrhea, andduring pregnancy because of the pressure of the enlarged uterus. Internal hemorrhoids are located in the inside lining of the rectum and cannot be felt. They are usually painless and make their presence known because blood is seen with a bowel movement. Internal hemorrhoids can prolapse or protrude through the anus. External hemorrhoids are located underneath the skin that surrounds the anus. They can be felt when they swell and may cause itching, pain, or bleeding with a bowel movement. A thrombosed external hemorrhoid occurs when blood within the vein clots, and may cause significant pain.

Hemorrhoid Causes
Hemorrhoids are associated with constipation and straining at bowel movements. Pregnancy is also associated with hemorrhoids. These conditions lead to increased pressure within the hemorrhoidal veins that causes them to swell. Other conditions, for example chronic liver disease, may also cause increased venous pressure and may be associated with hemorrhoids. Hemorrhoids are very common and are estimated to occur in up to one-half of the population by age 50.

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Hemorrhoid Symptoms
The most common symptom and sign from hemorrhoids is painless bleeding. There may be bright red blood on the outside of the stools, on the toilet paper, or dripping into the toilet. The bleeding usually is self-limiting. Bleeding with a bowel movement is never normal and should prompt a visit to a health care professional. While hemorrhoids are the most common cause of bleeding with a bowel movement, there may be other reasons for bleeding including inflammatory bowel disease, infection, and tumors.

Prolapsed Internal Hemorrhoids

Prolapse of an internal hemorrhoid occurs when the internal hemorrhoids swell and extend from their location in the rectum through the anus. A prolapsed internal hemorrhoid: can be felt as a lump outside the anus; can be gently pushed back through the anus, this may resolve the location of the hemorrhoid, but does not fix the hemorrhoid itself; may enlarge and swell even more if they cannot be pushed back; may become entrapped, which requires more urgent medical attention. Hemorrhoids may also cause pruritus ani or itching around the anus, and a constant feeling of needing to have a bowel movement (tenesmus).

Thrombosed External Hemorrhoids

Thrombosed external hemorrhoids are a painful condition. These occurs when ablood clot develops in a hemorrhoidal vein causing swelling and inflammation. When a blood clot occurs in a hemorrhoid, the hemorrhoid will become even more swollen. This swelling leads to increased pain. The pain is usually worse with bowel movements and may increase with sitting. A thrombosed external hemorrhoid may resolve on its own; however, this condition often needs medical care.

When to Seek Medical Care When to call the doctor

Bleeding from the rectum or anus is never normal and although hemorrhoids are the most common reason to have blood in the stool, it should be discussed with your primary health care professional. Other causes of rectal bleeding exist and can be serious. Inflammatory bowel disease andcancers of the colon can present with rectal bleeding. Blood in the stool should never be ignored. Medical care should be sought urgently if a person is taking anticoagulation medication such as warfarin (Coumadin), clopidogrel(Plavix), or prasugrel (Effient). Individuals who have associated symptoms such as lightheadedness and weakness may have significant blood loss and may require more urgent care. Hemorrhoids do not cause abdominal pain; should this be present with bleeding, medical care should be sought immediately. Prolapsed hemorrhoids that cannot be pushed back through the anus require medical care. Thrombosed external hemorrhoids may cause significant pain and medical care may be necessary to repair.

Hemorrhoid Diagnosis
Diagnosis of hemorrhoids is usually made by history and physical examination by the health care professional. Depending upon the situation, past medical history, medications and stability of the patient, treatment may follow with no further testing. Inspection of the anus and a digital rectal examination are often performed. Sometimes anoscopy may be required where a small, lighted scope is introduced into the anus to examine the inner lining of the anus and rectum. The procedure is often performed in the office without sedation. If there is the

potential that the bleeding source originated above the rectum from other parts of the colon,sigmoidoscopy or colonoscopy by a gastroenterologist may be recommended. If there is concern that significant bleeding has occurred, a CBC (complete blood count) to measure blood hemoglobin and hematocritlevels is obtained. If the patient is on warfarin (Coumadin), a prothrombin time (PT) or INR may be done to measure the blood clotting levels.

Hemorrhoid Treatment
There are several home remedies (warm sitz baths, dietary changes, stool softeners, exercise, OTC medication); or surgery to repair the hemorrhoid such as rubber band ligation, sclerotherapy, laser therapy, hemorrhoidectomy, and stapled hemorrhoidectomy.

Hemorrhoid Home Remedies

Symptomatic treatment for hemorrhoids can be done at home.

Warm Sitz Baths

Sitting in a few inches of warm water three times a day for 15 to 20 minutes may help decrease the inflammation of the hemorrhoids. It is important to dry off the anal area completely after each Sitz bath to minimize irritation of the skin surrounding the anus.

Dietary Changes
Increased fluid intake and dietary fiber (roughage) will decrease the potential for constipation and lessen the pressure on the rectum and anus during a bowel movement, minimizing further swelling, discomfort, and bleeding. Dietary fiber supplements may also help bulk up the stools

Stool Softeners
Stool softeners may help, but once hemorrhoids are present, liquid stools may cause inflammation and infection of the anus. A health care professional or pharmacist are good resources to discuss their use.

Activity Suggestions
Individuals with hemorrhoids should not sit for long periods of time and may benefit from sitting on an air or rubber donut available at most local pharmacies. Exercise is helpful in relieving constipation and in decreasing pressure on the hemorrhoidal veins. Individuals should be encouraged to have a bowel movement as soon as possible after the urge arises. Once that urge passes, stools can become constipated and straining with a bowel movement may occur.

Over-the-Counter Medications
Many creams, ointments, and suppositories are available for symptom relief and may be used for comfort. However, they do not "cure" hemorrhoids. Often they contain a numbing medication or a corticosteroid to decrease inflammation and swelling.

Hemorrhoid Medical Treatment Prolapsed Internal Hemorrhoids

Most prolapsed internal hemorrhoids can be pushed back into the anus, but occasionally your health care professional may need to reduce them by gently pushing them with constant pressure. If the hemorrhoids remain swollen and trapped outside the anus and they are not treated, the hemorrhoid tissue may not receive enough blood and can become infected. In such situations, surgery may be required to resolve the problem.

Thrombosed Hemorrhoids
Thrombosed external hemorrhoids can be painful and are associated with a hard lump that is felt at the anus and cannot be pushed back inside. Most often the clot within the hemorrhoid will need to be removed with a small incision. After local anesthetic is placed under the skin surrounding the hemorrhoid, a scalpel is used to cut into the area and the clot is removed. There is almost instant relief of the sharp pain but a dull ache may continue. There may be some mild bleeding from the hemorrhoid for a couple of days. Sitz baths and overthe-counter pain medications may be recommended. The use of a rubber or air rubber donut may help with the pain, and preventing constipation is a priority.

Hemorrhoid Surgery
A variety of surgical options exist for persistent pain or bleeding. Rubber band ligation: Rubber band ligation of internal hemorrhoids can be performed in the doctor's office. The surgeon places a couple of tight rubber bands around the base of the hemorrhoidal vein, which causes it to lose its blood supply. There may be some fullness or discomfort for 1 to 2 days after the procedure, and a minor amount of bleeding may be experienced.

Sclerotherapy
Sclerotherapy describes a procedure when a chemical is injected into the hemorrhoid, which causes it to scar and decrease in size.

Laser therapy:
Laser therapy can be used to scar and harden internal hemorrhoids.

Hemorrhoidectomy
Hemorrhoidectomy is a surgical procedure performed in the operating room with an anesthetic agent (general, spinal or local with sedation) where the whole hemorrhoid is removed (ectomy=removal). This is the most aggressive approach and there is a markedly decreased chance of the hemorrhoids returning. There is a potential for complications with this procedure; however, they occur less than 5% of the time. Complications include infection, bleeding, and stenosis where scarring causes the anus to narrow.

Stapled hemorrhoidectomy
Stapled hemorrhoidectomy is the newest surgical technique for treating hemorrhoids, and it has rapidly become the treatment of choice for severe hemorrhoid disease. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids, but instead tightens abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse

downward. Stapled hemorrhoidectomy is faster than traditional hemorrhoidectomy, taking approximately 30 minutes. It is associated with much less pain than traditional hemorrhoidectomy and patients usually return to normal activities and work sooner. Regardless of the surgery, Sitz baths and dietary suggestions for increased roughage are usually recommended.

Pictures of Stapled Hemorrhoidectomy Procedure

The following are pictures of the stapled hemorrhoidectomy procedure.

Picture of Internal Hemorrhoids in Anal Canal

Picture of Hollow Tube Inserted into the Anal Canal and Pushing up the Hemorrhoids

Picture of Suturing the Anal Canal through the Hollow Tube

Picture of Bringing Expanded Hemorrhoidal Supporting Tissue into the Hollow Tube by pulling On Suture

Picture of Hemorrhoids Pulled Back Above Anal Canal after Stapling and Removal of Hemorrhoidal Supporting Tissue Hemorrhoid Follow-up
Warm Sitz baths, plenty of fluids and increased roughage are usually recommended. Hemorrhoidal pain is usually managed with over-the-counter pain relievers. Stool softeners may be recommended by your health care professional. The person should contact their health care professional if they develop increased rectal pain, bleeding, fever, abdominal pain, or vomiting after hemorrhoid treatment.

Hemorrhoid Prevention
The risk of hemorrhoids can be decreased by eating a high fiber diet, staying well hydrated, getting regular exercise, and trying to have a bowel movement as soon as possible after the urge arises.

Hemorrhoid Prognosis
Most people with hemorrhoids have an excellent prognosis. While symptoms of bleeding or discomfort may flare from time to time, they don't last long and can be relieved with symptomatic care at home.

Synonyms and Keywords

internal hemorrhoids, external hemorrhoids,anal itching, anal bleeding, prolapsed hemorrhoid, prolapsed internal hemorrhoid, thrombosed hemorrhoid, piles, pruritus ani, sitz bath, laxative, hemorrhoidectomy, stapled hemorrhoidectomy, hemorrhoid surgery, ruber band ligation, laser therapy, sclerotherapy