What are hemorrhoids?

A precise definition of hemorrhoids does not exist, but they can be described as masses or
clumps ("cushions") of tissue within the anal canal that contain blood vessels and the
surrounding, supporting tissue made up of muscle and elastic fibers. The anal canal is the last
four centimeters through which stool passes as it goes from the rectum to the outside world. The
anus is the opening of the anal canal to the outside world.
Although most people think hemorrhoids are abnormal, they are present in everyone. It is only
when the hemorrhoidal cushions enlarge that hemorrhoids can cause problems and be considered
abnormal or a disease.
Prevalence of hemorrhoids
Although hemorrhoids occur in everyone, they become large and cause problems in only 4% of
the general population. Hemorrhoids that cause problems are found equally in men and women,
and their prevalence peaks between 45 and 65 years of age.
Anatomy of hemorrhoids
The arteries supplying blood to the anal canal descend into the canal from the rectum above and
form a rich network of arteries that communicate with each other around the anal canal. Because
of this rich network of arteries, hemorrhoidal blood vessels have a ready supply of arterial blood.
This explains why bleeding from hemorrhoids is bright red (arterial blood) rather than dark red
(venous blood), and why bleeding from hemorrhoids occasionally can be severe. The blood
vessels that supply the hemorrhoidal vessels pass through the supporting tissue of the
hemorrhoidal cushions.
The anal veins drain blood away from the anal canal and the hemorrhoids. These veins drain in
two directions. The first direction is upwards into the rectum, and the second is downwards
beneath the skin surrounding the anus. The dentate line is a line within the anal canal that
denotes the transition from anal skin (anoderm) to the lining of the rectum.
Formation of hemorrhoids
If the hemorrhoid originates at the top (rectal side) of the anal canal, it is referred to as an
internal hemorrhoid. If it originates at the lower end of the anal canal near the anus, it is
referred to as an external hemorrhoid. Technically, the differentiation between internal and
external hemorrhoids is made on the basis of whether the hemorrhoid originates above or below
the dentate line (internal and external, respectively).
As discussed previously, hemorrhoidal cushions in the upper anal canal are made up of blood
vessels and their supporting tissues. There usually are three major hemorrhoidal cushions
oriented right posterior, right anterior, and left lateral. During the formation of enlarged internal
hemorrhoids, the vessels of the anal cushions swell and the supporting tissues increase in size.

The bulging mass of tissue and blood vessels protrudes into the anal canal where it can cause
problems. Unlike with internal hemorrhoids, it is not clear how external hemorrhoids form

Hemorrhoid
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Hemorrhoids
Classification and external resources

Schematic demonstrating the anatomy of

hemorrhoids.
ICD-10

I84.

ICD-9

455

DiseasesDB

10036

MedlinePlus

000292

eMedicine

med/2821 emerg/242

MeSH

D006484

Hemorrhoids (US English) or haemorrhoids (Commonwealth English), are normal vascular

structures in the anal canal which help with stool control.[1][2] They become pathological or
known as piles[3] when swollen or inflamed. In their physiological state they act as cushions

composed of arterio-venous channels and connective tissue that aid the passage of stool. The
symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually
present with painless rectal bleeding while external hemorrhoids present with pain in the area of
the anus.
Recommended treatment consists of increasing fiber intake, oral fluids to maintain hydration,
NSAID analgesics, sitz baths, and rest. Surgery is reserved for those who fail to improve
following these measures.

Classification
There are two types of hemorrhoids, external and internal, which are differentiated via their
position with respect to the dentate line.[3]

[edit] External
External hemorrhoids are those that occur outside the anal verge (the distal end of the anal
canal). Specifically they are varicosities of the veins draining the territory of the inferior rectal
arteries, which are branches of the internal pudendal artery. They are sometimes painful, and
often accompanied by swelling and irritation. Itching, although often thought to be a symptom of
external hemorrhoids, is more commonly due to skin irritation. External hemorrhoids are prone
to thrombosis: if the vein ruptures and/or a blood clot develops, the hemorrhoid becomes a
thrombosed hemorrhoid.[4]

[edit] Internal
Internal hemorrhoids are those that occur inside the rectum. Specifically they are varicosities of
veins draining the territory of branches of the superior rectal arteries. 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. Untreated internal
hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated
hemorrhoids. 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.
Internal hemorrhoids can be further graded by the degree of prolapse.[3][5]

Grade I: No prolapse.
Grade II: Prolapse upon defecation but spontaneously reduce.

Grade III: Prolapse upon defecation and must be manually reduced.

Grade IV: Prolapsed and cannot be manually reduced.

[edit] Signs and symptoms

Hemorroids usually present with itching, rectal pain, or rectal bleeding.[2] In most cases,
symptoms will resolve within a few days. External hemorrhoids are painful while internal
hemorrhoids usually are not unless they become thrombosed or necrotic.[3][2]
The most common symptom of internal hemorrhoids is bright red blood covering the stool, a
condition known as hematochezia, on toilet paper, or in the toilet bowl.[2] They may protrude
through the anus. Symptoms of external hemorrhoids include painful swelling or lump around
the anus.

[edit] Causes
A number of factors may lead to the formations of hemorrhoids including irregular bowel habits
(constipation or diarrhea), exercise, nutrition (low-fiber diet), increased intra-abdominal pressure
(prolonged straining), pregnancy, genetics, absence of valves within the hemorrhoidal veins, and
aging.[3]
Other factors that can increase the rectal vein pressure resulting in hemorrhoids include obesity
and sitting for long periods of time.[6]
During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the
hemorrhoidal vessels to enlarge. Delivery also leads to increased intra abdominal pressures.[7][8]
Surgical treatment is rarely needed, as symptoms usually resolve post delivery.[3]

[edit] Pathophysiology
See also: Hemorrhoidal plexus

Hemorrhoid cushions are a part of normal human anatomy and only become a pathological
disease when they experience abnormal changes. There are three cushions present in the normal
anal canal.[3]
They are important for continence contributing to at rest 15%-20% of anal closure pressure and
act to protect the anal sphincter muscles during the passage of stool.[2]

[edit] Prevention
The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing
pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise,
including walking, and increased fiber in the diet help reduce constipation and straining by
producing stools that are softer and easier to pass.[9] Spending less time attempting to defecate
and avoiding reading while on the toilet have been recommended.[3]

[edit] Diagnosis
A visual examination of the anus and surrounding area may be able to diagnose external or
prolapsed hemorrhoids. A rectal exam may be performed to detect possible rectal tumors, polyps,
an enlarged prostate, or abscesses. This examination may not be possible without appropriate
sedation due to pain.[3]
Visual confirmation of internal hemorrhoids is via anoscopy. This device is basically a hollow
tube with a light attached at one end that allows one to see the internal hemorrhoids, as well
possible polyps in the rectum.

Direct view of a
Classical appearance of hemorrhoid as seen by
an external hemorrhoid. sigmoidoscopy

Endoscopic image of internal hemorrhoids

seen on retroflexion of the flexible
sigmoidoscope at the ano-rectal junction.

[edit] Differential
Many anorectal problems, including fissures, fistulae, abscesses, colorectal cancer, rectal varices
and itching have similar symptoms and may be incorrectly referred to as hemorrhoids.[3]

[edit] Treatments
Conservative treatment typically consists of increasing dietary fiber, oral fluids to maintain
hydration, non-steroidal anti-inflammatory drugs (NSAID)s, sitz baths, and rest.[3] Increased
fiber intake has been shown to improve outcomes[10] and may be achieved by dietary alterations
or the consumption of fibre supplements.[3][11]
While many topical agents and suppositories are available for the treatment of hemorrhoids there
is little evidence to support their use.[3] Preparation H may improve local symptoms but does not
improve the underlying disorder and long term use is discouraged due to local irritation of the
skin.[3]

[edit] Procedures

Rubber band ligation is a procedure in which elastic bands are applied onto
an internal hemorrhoid at least 1 cm above the dentate line to cut off its
blood supply.[3] Within 57 days, the withered hemorrhoid falls off. [3] If the
band is placed too close to the dentate line intense pain results immediately
afterwards.[3] Cure rate has been found to be about 87%. [3]

Sclerotherapy involves the injection of a sclerosing agent (such as phenol)

into the hemorrhoid. This causes the vein walls to collapse and the
hemorrhoids to shrivel up. The success rate at four years is 70%. [3]

A number of cautery methods have been shown to be effective for

hemorrhoids. This can be done using electrocautery, infrared radiation, [3] or
cryosurgery.[12]

A number of surgical techniques may be used if conservative medical management fails. All are
associated with some degree of complications including urinary retention, due to the close
proximity to the rectum of the nerves that supply the bladder, bleeding, infection, and anal
strictures.[3]

Hemorrhoidectomy is a surgical excision of the hemorrhoid used primary only

in severe cases.[3] It is associated with significant post operative pain and
usually requires 24 weeks for recovery. [3]
Doppler guided transanal hemorrhoidal dearterialization is a minimally
invasive treatment using an ultrasound doppler to accurately locate the
arterial blood inflow. These arteries are then tied off and the prolapsed
tissue is sutured back to its normal position. It has a slightly higher
recurrence rate however has less complications compared to a
hemorrhoidectomy.[3]
Stapled hemorrhoidectomy is a procedure that involves resection of soft
tissue proximal to the dentate line, disrupting the blood flow to the
hemorrhoids. It is generally less painful than complete removal of
hemorrhoids and was associated with faster healing compare to a
hemorrhoidectomy.[3]

[edit] Prognosis
Hemorrhoids are usually benign

[edit] Epidemiology
Symptomatic hemorrhoids affect at least 50% of the American population at some time during
their lives, with around 5% of the population suffering at any given time, and both sexes
experiencing the same incidence of the condition.[3][13] They are more common in Caucasians.[14]

[edit] Etymology
First attested in English 1398, the word hemmorrhoid derives from the Old French "emorroides",
from Latin "hmorrhoida -ae",[15] in turn from the Greek "" (haimorrhois), "liable to
discharge blood", from "" (haima), "blood"[16] + "" {rhoos), "stream, flow, current",[17]
itself from "" (rheo), "to flow, to stream".[18]

[edit] Notable cases

Hall-of-Fame baseball player George Brett was famously removed from a game in the 1980
World Series due to hemorrhoid pain. After undergoing minor surgery, Brett returned to play in
the next game, quipping "...my problems are all behind me."[19] Brett underwent further
hemorrhoid surgery the following spring.[