Hemorrhoids are clusters of vascular tissues, smooth muscles, and connective tissues that lie along the anal canal in three columns—left lateral, right anterior, and right posterior positions. Hemorrhoids are present universally in healthy individuals. Hemorrhoids aid in the process of bowel movement. Nonetheless, the term “hemorrhoid” is commonly invoked to characterize the pathologic process of symptomatic hemorrhoid disease instead of the normal anatomic structure.
As the supporting tissue of the anal cushions weakens, downward displacement of the cushions can occur, causing venous dilation and prolapse.
What Causes Hemorrhoids?
There’s no single cause of hemorrhoids. Most often, though, they are caused by too much pressure on the anal canal. This can be due to:
Classification of a hemorrhoid:
located below the dentate line and are covered with anoderm, composed of squamous epithelium, and are innervated by somatic nerves supplying the perianal skin and thus producing pain.
lie above the dentate line and are covered by columnar epithelium, innervated by visceral nerve fibers and thus cannot cause pain.
Symptoms and Presentation:
A total of 40% of individuals with hemorrhoids are asymptomatic. For symptomatic hemorrhoids, there is great variance in the constellation of symptoms.
For internal hemorrhoids,
In contrast, in external hemorrhoids,
Conservative Medical Treatments
Lifestyle and dietary modification are the mainstays of conservative medical treatment of hemorrhoid disease. Specifically, lifestyle modifications should include increasing oral fluid intake, reducing fat consumptions, avoiding straining, and regular exercise.
Diet recommendations should include increasing fiber intake, which decreases the shearing action of passing hard stool.
Nonsurgical Office-based Procedures
Rubber Band Ligation
Rubber band ligation is the most commonly performed procedure in the office and is indicated for grade II and III internal hemorrhoids
Sclerotherapy is indicated for patients with grade I and II internal hemorrhoids and may be a good option for patients on anticoagulants.
Infrared coagulation refers to direct application of infrared light waves to the hemorrhoidal tissues and can be used for grade I and II internal hemorrhoids
Based on the concept that freezing the internal hemorrhoid at low temperatures can lead to tissue destruction
For symptomatic Grade ΙΙΙ-ΙV hemorrhoids and hemorrhoids resistant to nonoperative procedures, a surgical approach can be adopted. This is required in only 5-10% of patients.
There are two major types of hemorrhoidectomy:
Ferguson, or closed hemorrhoidectomy and
Milligan–Morgan, or open hemorrhoidectomy
An alternative to operative hemorrhoidectomy is stapled hemorrhoidopexy, in which a circular stapling device is used to resect and fixate the internal hemorrhoid tissues to the rectal wall. This technique is also known as ‘procedure for prolapse and hemorrhoids (PPH)’. PPH is significantly less painful and allows quicker recovery.
Doppler-guided Hemorrhoidal Artery Ligation
It involves a Doppler transducer allowing sequential identification of the position and depth of superior rectal arterial branches, which are then selectively ligated 2-3 cm above the dentate line. The interference with the blood supply suppresses the bleeding and volume of the hemorrhoids and symptomatic relief is usually evident within 6-8 weeks.