Hemorrhoid

Hemorrhoids (AmE), haemorrhoids (BrE), emerods, or piles are varicosities or swelling and
inflammation of veins in the rectum and anus. The anatomical term "hemorrhoids" technically
refers to "'Cushions of tissue filled with blood vessels at the junction of the rectum and the
anus."[1] However, the term is popularly used to refer to varicosities of the hemorrhoid tissue.
Perianal hematoma are sometimes misdiagnosed and mislabeled as hemorrhoids, when in fact
they have different causes and treatments.[2]

Schematic demonstrating the anatomy of hemorrhoids.

Contents
[hide]

1 Prevalence
2 Causes
o

2.1 Symptoms

2.2 Food

3 Types of hemorrhoids
o

3.1 By degree of prolapse

4 Prevention
o

4.1 Use of squat toilets

5 Examination

6 Treatments
o

6.1 Natural treatments

6.2 Surgical and non-medicinal treatments

6.3 Diseases with similar symptoms

7 References

8 See also

9 External links

Prevalence
Hemorrhoids are common. In the USA, the prevalence is about 4.4%.[3][4] It is estimated that
approximately one half of all Americans have had this condition by the age of 50, and that 50%
to 85% of the world's population will be affected by hemorrhoids at some time in their life.[citation
needed]
Annually, about 10% to 20% of patients with symptomatic hemorrhoids require surgery.[5]
According to a British medical journal of 1972 hemorrhoids "are common in economically
developed communities, rare in developing countries, and almost unknown in tribal
communities, where the influence of Western countries is slight."[6]

Causes
Increased straining during bowel movements, by constipation or diarrhea, may lead to
hemorrhoids.[7] It is thus a common condition due to constipation caused by water retention in
women experiencing premenstrual syndrome or menstruation.
Hypertension, particularly portal hypertension, can also cause hemorrhoids because of the
connections between the portal vein and the vena cava which occur in the rectal wall -- known as
portocaval anastomoses.[8]
Obesity can be a factor by increasing rectal vein pressure. Sitting for prolonged periods of time
can cause hemorrhoids. Poor muscle tone or poor posture can result in too much pressure on the
rectal veins.
Pregnancy causes hypertension and increases strain during bowel movements, so hemorrhoids
are often associated with pregnancy.
Excessive consumption of alcohol or caffeine can cause hemorrhoids.[9] Both can cause diarrhea.
Note that caffeine ingestion increases blood pressure transiently, but is not thought to cause
chronic hypertension. Alcohol can also cause alcoholic liver disease leading to portal
hypertension.
Symptoms

Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching, also
called pruritus ani, have similar symptoms and are incorrectly referred to as hemorrhoids.
Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal
symptoms will go away within a few days.

Although many people have hemorrhoids, not all experience symptoms. The most common
symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the
toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body,
becoming irritated and painful. This is known as a protruding hemorrhoid.
Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus
that results when a blood clot forms. This condition is known as a thrombosed external
hemorrhoid.
In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with
bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may
also cause itching.
Food
This section does not cite any references or sources.
Please help improve this section by adding citations to reliable sources. Unverifiable
material may be challenged and removed. (September 2006)

Insufficient liquid can cause a hard stool, or even chronic constipation, which can lead to
hemorrhoidal irritation. An excess of lactic acid in the stool, a product of excessive consumption
of dairy products such as cheese, can cause irritation; reducing such consumption can bring
relief. Vitamin E deficiency is also a common cause.
Eating fruit helps avoid conditions that lead to hemorrhoids.
Food considered "probiotic", such as yogurt with active culture, may help keep the gut
functioning normally and thus prevent flare-ups.

Types of hemorrhoids

(I84.3-I84.5) External hemorrhoids are those that occur outside of the anal verge (the
distal end of the anal canal). They are sometimes painful, and can be accompanied by
swelling and irritation. Itching, although often thought to be a symptom from external
hemorrhoids, is more commonly due to skin irritation.
o (I84.3) External hemorrhoids are prone to thrombosis: if the vein ruptures and a
blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid.[10]

(I84.0-I84.2) Internal hemorrhoids are those that occur inside the rectum. As this area
lacks pain receptors, internal hemorrhoids are usually not painful and most people are not
aware that they have them. Internal hemorrhoids, however, may bleed when irritated.

(I84.1) Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids:
prolapsed and strangulated hemorrhoids:
o

Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they
are pushed outside the anus.

If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid
outside the anal opening, the supply of blood is cut off, and the hemorrhoid
becomes a strangulated hemorrhoid.

Direct view of hemorrhoid seen on sigmoidoscopy

By degree of prolapse

The most common grading system was developed by Banov:[3][11]

Grading of Internal Hemorrhoids

o Grade I: The hemorrhoids do not prolapse.
o

Grade II: The hemorrhoids prolapse upon defecation but

spontaneously reduce.

Grade III: The hemorrhoids prolapse upon defecation, but must be

manually reduced.

Grade IV: The hemorrhoids are prolapsed and cannot be manually

reduced.

Prevention
This section does not cite any references or sources.
Please help improve this section by adding citations to reliable sources. Unverifiable
material may be challenged and removed. (September 2006)

Prevention of hemorrhoids includes drinking more fluids, eating more dietary fiber (such as
fruits, vegetables and cereals high in fiber), exercising, practicing better posture, and reducing
bowel movement strain and time. Hemorrhoid sufferers should avoid using laxatives and should
strictly limit time straining during bowel movement. Wearing tight clothing and underwear will
also contribute to irritation and poor muscle tone in the region and promote hemorrhoid
development. Some sufferers report a more comfortable experience without underwear or
wearing only very lightweight underwear.

Women who notice they have painful stools around the time of menstruation would be welladvised to begin taking extra dietary fiber and fluids a couple days prior to that time.
Fluids emitted by the intestinal tract may contain irritants that may increase the fissures
associated with hemorrhoids. Washing the anus with cool water and soap may reduce the
swelling and increase blood supply for quicker healing and may remove irritating fluid.
Kegel exercises for the pelvic floor may also prove helpful.
Many people do not get a sufficient supply of dietary fiber (20 to 25 grams daily) and small
changes in a person's daily diet can help tremendously in both prevention and treatment of
hemorrhoids.
Use of squat toilets

Based on their very low incidence in the developing world, where people squat for bodily
functions, hemorrhoids have been attributed to the use of the unnatural "sitting" toilet.[12][13] In
1987, an Israeli physician, Dr. Berko Sikirov, published a study testing this hypothesis by having
hemorrhoid sufferers convert to squat toilets.[14] Eighteen of the 20 patients were completely
relieved of their symptoms (pain and bleeding) with no recurrence, even 30 months after
completion of the study. This chart summarizes the results.
No follow-up studies have ever been published. The American Society of Colon & Rectal
Surgeons is silent regarding the therapeutic value of squatting.

Examination
After visual examination of the anus and surrounding area for external or prolapsed hemorrhoids,
a doctor would conduct a digital examination. In addition to probing for hemorrhoidal bulges, a
doctor would also look for indications of rectal tumor or polyp, enlarged prostate and abscesses.
Visual confirmation of hemorrhoids can be done by doing an anoscopy, using a medical device
called an anoscope. This device is basically a hollow tube with a light attached at one end that
allows the doctor to see the internal hemorrhoids, as well as polyps in the rectum.
If warranted, more detailed examinations, such as sigmoidoscopy and colonoscopy can be
performed. In sigmoidoscopy, the last 60cm of the colon and rectum are examined whereas in
colonoscopy the entire bowel is examined.
A pathologist will look for dilated vascular spaces which exhibit thrombosis and recanalization.

Treatments
Treatments for hemorrhoids vary in their cost, risk, and effectiveness. Different cultures and
individuals approach treatment differently. Some of the treatments used are listed here in
increasing order of intrusiveness and cost.

For many people, hemorrhoids are mild and temporary conditions that heal spontaneously or by
the same measures recommended for prevention. There is no medicine that will cure
hemorrhoids but local treatments such as warm sitz baths, using a bidet, extendable showerhead,
cold compress, or topical analgesic (such as Nupercainal), can also provide temporary relief.
Especially in the case of external hemorrhoids with a visible lump of small size, the condition
can be improved with warm bath causing the vessels around rectal region to be relaxed.
Consistent use of medicated creams during the early stages of a hemorrhoid flare-up will also
provide relief and may stave off further development and irritation. However, creams containing
steroid preparations weaken the skin and may contribute to further flare-ups. Keep the area clean
and dry, with some lubrication provided by hemorrhoidal creams or a lubricant. Ointment or
suppositories such as Proctosedyl[15][16] and Faktu[17] can also relieve the symptoms.
Natural treatments

Some people claim to have successfully applied natural procedures for treatment or reversal of
chronic conditions. These procedures largely echo the prevention measures. However, self-care
measures, including herbal or "natural" remedies, should not be undertaken without medical
consent to avoid possible drug interactions. They include:

Reducing regional pressure in such ways as improving posture and muscle

tone, or in severe cases, undergoing a profound psychophysical reeducation,
by a method such as the Alexander Technique.
Taking herbs and dietary supplements that strengthen vein walls, such as
Butcher's Broom, Horse-chestnut, bromelain, and Japanese Pagoda Tree
extracts. Drinking 99% pure aloe juice can also relieve itching and swelling.
[citation needed]

Topical application of natural astringents and soothing agents, such as Witch

hazel (astringent), Cranesbill, Aloe vera, and honey.

Drinking chamomile tea several times a day.

Eating fiber-rich bulking agents such as plantain and Psyllium seed husks to
help create a softer stool that is easier to pass, to lessen the irritation of
existing hemorrhoids.

Using the squatting position for bowel movements. [18]

For sufferers of hemorrhoids caused by poor vein circulation (coupled with

varicose veins in lower extremities and/or varicocele), sleeping overnight with
raised legs helps reduce or completely eliminate especially external
hemorrhoids.

The combination of internal and external remedies is particularly recommended, e.g., Witchhazel suppositories combined with frequent cups of strong chamomile tea.[19]

Dietary supplements can help treat and prevent many complications of hemorrhoids, and natural
botanicals such as Butchers Broom, Horse-chestnut, and bioflavonoids can be an effective
addition to hemorrhoid treatment.[20]
Butcher's Broom extract, or Ruscus aculeatus, contains ruscogenins that have anti-inflammatory
and vasoconstrictor effects that help tighten and strengthen veins. Butchers Broom has
traditionally been used to treat venous problems including hemorrhoids and varicose veins.[21][22]
[23]

Horse-chestnut extract, or Aesculus hippocastanum, contains a saponin known as aescin, that has
anti-inflammatory, anti-edema, and venotonic actions. Aescin improves tone in vein walls,
thereby strengthening the support structure of the vein. Double blind studies have shown that
supplementation with Horse-chestnut helps relieve the pain and swelling associated with chronic
venous insufficiency.[24][25]
Bilberry extract, or Vaccinium myrtillus, is an anthocyanoside bioflavonoid. Supplementation
with this potent flavonoid protects and maintains venous strength and function.[21][26]
Surgical and non-medicinal treatments

Some people require the following medical treatments for chronic or severe hemorrhoids:

Rubber band ligation

Sometimes called Baron ligation. Elastic bands are applied onto an internal
hemorrhoid to cut off its blood supply.[27] Within several days, the withered
hemorrhoid is sloughed off during normal bowel movement.
Hemorrhoidolysis/Galvanic Electrotherapy
Desiccation of the hemorrhoid by electrical current.

Sclerotherapy (injection therapy)

Sclerosant or hardening agent is injected into hemorrhoids. This causes the
vein walls to collapse and the hemorrhoids to shrivel up.

Cryosurgery
A frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues. [28] Rarely
used anymore because of side effects.

Laser, infrared or BICAP coagulation

Laser, infrared beam, or electricity is used to cauterize the affected tissues.
Lasers are now much less popular. Infrared coagulation has been studied in
comparison with RBL and found to be as effective in hemorrhoids up to grade
III. These are the most readily available non-surgical procedures in the US.

Hemorrhoidectomy
A true surgical procedure to excise and remove hemorrhoids. Has possible
correlation with incontinence issues later in life; in addition, many patients
complain that pain during recovery is severe. For this reason is often now
recommended only for severe (grade IV) hemorrhoids.

Stapled Hemorrhoidectomy
Also called the procedure for prolapse and hemorrhoids, it is designed to
resect soft tissue proximal to the dentate line, which disrupts the blood flow
to the hemorrhoids. It is generally less painful than complete removal of
hemorrhoids and also allows for faster recovery times. It's meant for
hemorrhoids that fall out or bleed and is not helpful for painful outside
conditions.

Enema
This practice is used to clean the rectum. While it is a simple procedure, it
can be complicated by hemorrhoids, so in such cases, it should be done by a
doctor. In an enema, water is injected into the rectum and then flushed out,
cleaning the area.

Doppler Guided Hemorrhoidal Artery Ligation

The only evidence-based surgery for all grades of hemorrhoids. It does not
involve cutting tissues or even a stay at the hospital; patients are usually
back to work on the same day. It is the best treatment for bleeding piles, as
the bleeding stops immediately. [29]

HAL-RAR
To date, Doppler Guided Hemorrhoidal Artery Ligation was indicated in
management of Grade II & Grade III Hemorrhoids but with the availabilty of
HAL Recto Anal Repair Management of prolapsing hemorrhoids without
excision is also possible.

Transanal hemorrhoidal dearterialization (THD)

Similar to HAL, but more standardizable and therefore safer, less painful and
has a shorter recovery time.

Diseases with similar symptoms

Symptoms associated with rectal cancer, anal fissure, anal abscess, anal fistula, Perianal
hematoma, and other diseases may be similar to those produced by hemorrhoids and may be
reduced by the topical analgesic methods described above. For this reason, it is a good idea to
consult with a physician when these symptoms are encountered, particularly for the first time,
and periodically should the problem continue. In the US, colonoscopy is recommended as a
general diagnostic for those over age 50 (40 with family history of bowel cancers); a clear
(normal) scope is good for 10 years.

References
1. ^ MedlinePlus Medical Encyclopedia:Hemorrhoid surgery - series: Normal
anatomy
2. ^ Perianal hematoma - Medbroadcast
3. ^

a b

Hemorrhoid at eMedicine

4. ^ Johanson JF, Sonnenberg A (1990). "The prevalence of hemorrhoids and

chronic constipation. An epidemiologic study". Gastroenterology 98 (2): 380
6. PMID 2295392.

5. ^ http://citvideosla.cit.nih.gov/captions/captions13/consensus121107%20%20WO%2382557.doc
6. ^ Burkitt, DP, Varicose Veins, Deep Vein Thrombosis, and Haemorrhoids:
Epidemiology and Suggested Aetiology,Br Med J. 1972 June 3; 2(5813): 556
561.link to article
7. ^ Harms R (November 3, 2007). "Hemorrhoids during pregnancy: Treatment
options". MayoClinic. Retrieved on 2007-11-28.
8. ^ "Causes of Hemorrhoids". Mayo Clinic (November 28, 2006). Retrieved on
2007-12-07.
9. ^ Burney RE (November 2005). "Hemorrhoids". University of Michigan Health
System. Retrieved on 2007-11-28.
10.^ E. Gojlan, Pathology, 2nd ed. Mosby Elsevier, Rapid Review series.
11.^ Banov L, Knoepp LF, Erdman LH, Alia RT (1985). "Management of
hemorrhoidal disease". J S C Med Assoc 81 (7): 398401. PMID 3861909.
12.^ Sikirov BA (1989). "Primary constipation: an underlying mechanism". Med.
Hypotheses 28 (2): 713. doi:10.1016/0306-9877(89)90016-9. PMID
2927355.
13.^ Sikirov D (2003). "Comparison of straining during defecation in three
positions: results and implications for human health". Dig. Dis. Sci. 48 (7):
12015. doi:10.1023/A:1024180319005. PMID 12870773.
14.^ Sikirov BA (1987). "Management of hemorrhoids: a new approach". Isr. J.
Med. Sci. 23 (4): 2846. PMID 3623887.
15.^ Proctosedyl ointment/suppositories
16.^ Proctosedyl - Drugs - Medbroadcast
17.^ http://www.vghks.gov.tw/ph/%E8%99%95%E6%96%B9%E9%9B
%86/drug/faktu.htm
18.^ Christine Dimmer, Brian Martin, Noeline Reeves and Frances Sullivan
(October 1996). "Squatting for the Prevention of Hemorrhoids". Townsend
Letter for Doctors & Patients (159): 6670.
19.^ K. Kraft and C. Hobbs, Pocket Guide to Herbal Medicine. New York: Thieme.
20.^ MacKay D (2001). "Hemorrhoids and varicose veins: a review of treatment
options" (PDF). Altern Med Rev 6 (2): 12640. PMID 11302778.
21.^ a b (1998) in Pizzorno JE and Murray MT, eds.: Encyclopedia of Natural
Medicine, revised 2nd edition, CA: Prima Publishing, 829.
22.^ Rudofsky G (1989). "[Improving venous tone and capillary sealing. Effect of
a combination of Ruscus extract and hesperidine methyl chalcone in healthy

probands in heat stress]" (in German). Fortschr. Med. 107 (19): 52, 558.
PMID 2668140.
23.^ Cappelli R, Nicora M, Di Perri T (1988). "Use of extract of Ruscus aculeatus
in venous disease in the lower limbs". Drugs Exp Clin Res 14 (4): 27783.
PMID 3048951.
24.^ Pittler MH, Ernst E (1998). "Horse-chestnut seed extract for chronic venous
insufficiency. A criteria-based systematic review". Arch Dermatol 134 (11):
135660. doi:10.1001/archderm.134.11.1356. PMID 9828868.
25.^ Diehm C, Trampisch HJ, Lange S, Schmidt C (1996). "Comparison of leg
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patients with chronic venous insufficiency". Lancet 347 (8997): 2924.
doi:10.1016/S0140-6736(96)90467-5. PMID 8569363.
26.^ Murray MT. (1996). Encyclopedia of Nutritional Supplements. NY: Three
Rivers Press, 326.
27.^ Longman RJ, Thomson WH (2006). "A prospective study of outcome from
rubber band ligation of piles". Colorectal Dis 8 (2): 1458. doi:10.1111/j.14631318.2005.00873.x. PMID 16412076.
28.^ MacLeod JH (1982). "In defense of cryotherapy for hemorrhoids. A modified
method". Dis. Colon Rectum 25 (4): 3325. PMID 6979469.
29.^ Scheyer M, Antonietti E, Rollinger G, Mall H, Arnold S (2006). "Dopplerguided hemorrhoidal artery ligation". Am. J. Surg. 191 (1): 8993.
doi:10.1016/j.amjsurg.2005.10.007. PMID 16399113.

See also

Anal fissure
Anal fistula

Perianal hematoma

Proctoscopy

Anal abscess

External links

Hemorrhoid at the Open Directory Project

Cardiovascular disease: vascular disease - Circulatory system

pathology (I70-I99, 440-459)

Arteries Arterial Arteriosclerosis: Atherosclerosis - Intermittent claudication -

Atheroma - Monckeberg's arteriosclerosis

occlusiv
Stenosis (Renal artery stenosis, Carotid artery stenosis) e
Fibromuscular dysplasia - Degos disease - Aortoiliac occlusive
disease
disease

Peripher
al
vascula Raynaud's phenomenon/Raynaud's disease - Erythromelalgia
,
r
arteriol
disease
es
and
capillari
Aortic aneurysm/Abdominal aortic aneurysm - Cerebral aneurysm es
Aneurys
Coronary artery aneurysm - Intracranial berry aneurysm m
Dissection (Aortic, Carotid, Vertebral) - Pseudoaneurysm

Arteritis (Aortitis) - Buerger's disease

Other

Arteriovenous fistula - Hereditary hemorrhagic telangiectasia

Nevus (Spider angioma, Halo nevus)

primarily lower limb (Deep vein thrombosis)

abdomen (May-Thurner syndrome, Portal vein thrombosis, BuddVenous

thrombosis/ Chiari syndrome, Renal vein thrombosis)
Phlebitis/
upper limb (Paget-Schroetter disease)
Thrombophle
bitis
head (Cerebral venous sinus thrombosis)

Veins

Post-thrombotic syndrome

Varicose veins

Varicocele - Gastric varices - Portacaval anastomosis

(Hemorrhoid, Esophageal varices, Caput medusae)

Other

Superior vena cava syndrome - Inferior vena cava syndrome

- Venous ulcer

Arteries Vasculitis - Thrombosis - Embolism (Pulmonary embolism, Cholesterol

or veins embolism)

Lympha
tic
Lymphadenitis - Lymphedema - Lymphangitis
disease

Blood
pressur
e

Hypertensi Hypertensive heart disease - Hypertensive nephropathy on

Secondary hypertension (Renovascular hypertension)

Hypotensi
Orthostatic hypotension
on

(from : http://en.wikipedia.org/wiki/Hemorhoids)