Drugs & Diseases > Emergency Medicine
Hemorrhoids
Updated: Sep 24, 2019
Author: Kyle R Perry, MD; Chief Editor: John Geibel, MD, MSc, DSc,
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Background
Hemorrhoids are swollen blood vessels in the lower rectum. They are
among the most common causes of anal pathology, and subsequently are
blamed for virtually any anorectal complaint by patients and medical
professionals alike. Confusion often arises because the term "hemorrhoid"
has been used to refer to both normal anatomic structures and pathologic
structures. In the context of this article, "hemorrhoids" refers to the
pathologic presentation of hemorrhoidal venous cushions.
Hemorrhoidal venous cushions are normal structures of the anorectum and
are anatomically present unless a previous intervention has taken place.
Because of their rich vascular supply, highly sensitive location, and
tendency to engorge and prolapse, hemorrhoidal venous cushions are
common causes of anal pathology. [1] Symptoms can range from mildly
bothersome, such as pruritus, to quite concerning, such as rectal bleeding.
Although hemorrhoids are a common condition diagnosed in clinical
practice, many patients are too embarrassed to seek treatment.
Consequently, the true prevalence of pathologic hemorrhoids is not
known. [2] In addition, although hemorrhoids are responsible for a large
portion of anorectal complaints, it is important to rule out more serious
conditions, such as other causes of gastrointestinal (GI) bleeding, before
reflexively attributing symptoms to hemorrhoids. [3]
In a study of 198 physicians from different specialties, Grucela et al found
the rate of correct identification for seven common, benign anal pathologic
conditions (including anal abscess, fissure, and fistula; prolapsed internal
hemorrhoid; thrombosed external hemorrhoid; condyloma acuminata; and
full-thickness rectal prolapse) was greatest for condylomata and rectal
prolapse and was lowest for hemorrhoidal conditions. [4] There was no
correlation between diagnostic accuracy and years of physician
experience. The investigators found the overall diagnostic accuracy among
the physicians to be 53.5%, with the accuracy for surgeons being 70.4%
and that for the rest of the doctors being less than 50%. [4]
Historical note
Hemorrhoidal symptoms have historically been treated with dietary
modifications, incantations, voodoo, quackery, and application of a hot
poker. Molten lead has also been described as a treatment. The adverse
effects of these treatments have a direct relationship to whether patients
relay persistent or recurrent complaints to the clinician or return for further
treatment.
For patient education information, see the Digestive Disorders Center as
well as Hemorrhoids, Anal Abscess, Rectal Pain, and Rectal Bleeding.
See also the following:
Anal Surgery for Hemorrhoids
Thrombosed External Hemorrhoid Excision
Anatomy
Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg,
arterioles, venules, arteriolar-venular connections), smooth muscle (eg,
Treitz muscle), and connective tissue lined by the normal epithelium of the
anal canal. Hemorrhoids are present in utero and persist through normal
adult life. Evidence indicates that hemorrhoidal bleeding is arterial and not
venous. This evidence is supported by the bright red color and arterial pH
of the blood.
Hemorrhoids are classified by their anatomic origin within the anal canal
and by their position relative to the dentate line; thus, they are categorized
into internal and external hemorrhoids (see the following image).
Hemorrhoids. Anatomy of
external hemorrhoid. Image courtesy of MedicineNet, Inc.
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External hemorrhoids develop from ectoderm and are covered by
squamous epithelium, whereas internal hemorrhoids are derived from
embryonic endoderm and lined with the columnar epithelium of anal
mucosa. Similarly, external hemorrhoids are innervated by cutaneous
nerves that supply the perianal area. These nerves include the pudendal
nerve and the sacral plexus. Internal hemorrhoids are not supplied by
somatic sensory nerves and therefore cannot cause pain. At the level of the
dentate line, internal hemorrhoids are anchored to the underlying muscle
by the mucosal suspensory ligament.
Hemorrhoidal venous cushions are a normal part of the human anorectum
and arise from subepithelial connective tissue within the anal canal. Internal
hemorrhoids have three main cushions, which are situated in the left
lateral, right posterior (most common), and right anterior areas of the anal
canal. However, this combination is found in only 19% of patients;
hemorrhoids can be found at any position within the rectum. Minor tufts can
be found between the major cushions.
Present in utero, these cushions surround and support distal anastomoses
between the superior rectal arteries and the superior, middle, and inferior
rectal veins. They also contain a subepithelial smooth muscle layer,
contributing to the bulk of the cushions. Normal hemorrhoidal tissue
accounts for approximately 15-20% of resting anal pressure and provides
important sensory information, enabling the differentiation between solid,
liquid, and gas.
External hemorrhoidal veins are found circumferentially under the anoderm;
they can cause trouble anywhere around the circumference of the anus.
Venous drainage of hemorrhoidal tissue mirrors embryologic origin. Internal
hemorrhoids drain through the superior rectal vein into the portal system.
External hemorrhoids drain through the inferior rectal vein into the inferior
vena cava. Rich anastomoses exist between these two and the middle
rectal vein, connecting the portal and systemic circulations.
Mixed hemorrhoids are confluent internal and external hemorrhoids.
Etiology and Pathophysiology
The term hemorrhoid is usually related to the symptoms caused by
hemorrhoids. Hemorrhoids are present in healthy individuals. In fact,
hemorrhoidal columns exist in utero. When these vascular cushions
produce symptoms, they are referred to as hemorrhoids. Hemorrhoids
generally cause symptoms when they become enlarged, inflamed,
thrombosed, or prolapsed.
Most symptoms arise from enlarged internal hemorrhoids. Abnormal
swelling of the anal cushions causes dilatation and engorgement of the
arteriovenous plexuses. This leads to stretching of the suspensory muscles
and eventual prolapse of rectal tissue through the anal canal. The
engorged anal mucosa is easily traumatized, leading to rectal bleeding that
is typically bright red due to high blood oxygen content within the
arteriovenous anastomoses. Prolapse leads to soiling and mucus
discharge (triggering pruritus) and predisposes to incarceration and
strangulation.
Although many patients and clinicians believe that hemorrhoids are caused
by chronic constipation, prolonged sitting, and vigorous straining, little
evidence to support a causative link exists. Some of these potential
etiologies are briefly discussed below.
Decreased venous return
Most authors agree that low-fiber diets cause small-caliber stools, which
result in straining during defecation. This increased pressure causes
engorgement of the hemorrhoids, possibly by interfering with venous
return. Pregnancy and abnormally high tension of the internal sphincter
muscle can also cause hemorrhoidal problems, presumably by means of
the same mechanism, which is thought to be decreased venous return.
Prolonged sitting on a toilet (eg, while reading) is believed to cause a
relative venous return problem in the perianal area (a tourniquet effect),
resulting in enlarged hemorrhoids. Aging causes weakening of the support
structures, which facilitates prolapse. Weakening of support structures can
occur as early as the third decade of life.
Straining and constipation
Straining and constipation have long been thought of as culprits in the
formation of hemorrhoids. This may or may not be true. [5,6, 7] Patients who
report hemorrhoids have a canal resting tone that is higher than normal. Of
interest, the resting tone is lower after hemorrhoidectomy than it is before
the procedure. This change in resting tone is the mechanism of action of
Lord dilatation, a surgical procedure for anorectal complaints that is most
commonly performed in the United Kingdom.
Pregnancy
Pregnancy clearly predisposes women to symptoms from hemorrhoids,
although the etiology is unknown. Notably, most patients revert to their
previously asymptomatic state after delivery. The relationship between
pregnancy and hemorrhoids lends credence to hormonal changes or direct
pressure as the culprit.
Portal hypertension and anorectal varices
Portal hypertension has often been mentioned in conjunction with
hemorrhoids.[8, 9, 10] However, hemorrhoidal symptoms do not occur more
frequently in patients with portal hypertension than in those without it, and
massive bleeding from hemorrhoids in these patients is unusual. Bleeding
is very often complicated by coagulopathy. If bleeding is found, direct
suture ligation of the offending column is suggested.
Anorectal varices are common in patients with portal
hypertension. [11] Varices occur in the midrectum, at connections between
the portal system and the middle and inferior rectal veins. Varices occur
more frequently in patients who are noncirrhotic, and they rarely bleed.
Treatment is usually directed at the underlying portal hypertension.
Emergent control of bleeding can be obtained with suture ligation.
Portosystemic shunts and transjugular intrahepatic portosystemic shunts
(TIPS) have been used to control hypertension and thus, the bleeding. [12]
Other risk factors
Other risk factors historically associated with the development of
hemorrhoids include the following:
Lack of erect posture
Familial tendency
Higher socioeconomic status
Chronic diarrhea
Colon malignancy
Hepatic disease
Obesity
Elevated anal resting pressure
Spinal cord injury
Loss of rectal muscle tone
Rectal surgery
Episiotomy
Anal intercourse
Inflammatory bowel disease, including ulcerative colitis, and Crohn
disease
Pathophysiology of symptoms of internal hemorrhoids
Internal hemorrhoids cannot cause cutaneous pain, because they are
above the dentate line and are not innervated by cutaneous nerves.
However, they can bleed, prolapse, and, as a result of the deposition of an
irritant onto the sensitive perianal skin, cause perianal itching and irritation.
Internal hemorrhoids can produce perianal pain by prolapsing and causing
spasm of the sphincter complex around the hemorrhoids. This spasm
results in discomfort while the prolapsed hemorrhoids are exposed. This
muscle discomfort is relieved with reduction.
Internal hemorrhoids can also cause acute pain when incarcerated and
strangulated. Again, the pain is related to the sphincter complex spasm.
Strangulation with necrosis may cause more deep discomfort. When these
catastrophic events occur, the sphincter spasm often causes concomitant
external thrombosis. External thrombosis causes acute cutaneous pain.
This constellation of symptoms is referred to as acute hemorrhoidal crisis
and usually requires emergent treatment.
Internal hemorrhoids most commonly cause painless bleeding with bowel
movements. The covering epithelium is damaged by the hard bowel
movement, and the underlying veins bleed. With spasm of the sphincter
complex elevating pressure, the internal hemorrhoidal veins can spurt.
Internal hemorrhoids can deposit mucus onto the perianal tissue with
prolapse. This mucus with microscopic stool contents can cause a localized
dermatitis, which is called pruritus ani. Generally, hemorrhoids are merely
the vehicle by which the offending elements reach the perianal tissue.
Hemorrhoids are not the primary offenders.
Pathophysiology of symptoms of external hemorrhoids
External hemorrhoids cause symptoms in two ways. First, acute thrombosis
of the underlying external hemorrhoidal vein can occur. Acute thrombosis is
usually related to a specific event, such as physical exertion, straining with
constipation, a bout of diarrhea, or a change in diet. These are acute,
painful events.
Pain results from rapid distention of innervated skin by the clot and
surrounding edema. The pain lasts 7-14 days and resolves with resolution
of the thrombosis. With this resolution, the stretched anoderm persists as
excess skin or skin tags. External thromboses occasionally erode the
overlying skin and cause bleeding. Recurrence occurs approximately 40-
50% of the time, at the same site (because the underlying damaged vein
remains there). Simply removing the blood clot and leaving the weakened
vein in place, rather than excising the offending vein with the clot, will
predispose the patient to recurrence.
External hemorrhoids can also cause hygiene difficulties, with the excess,
redundant skin left after an acute thrombosis (skin tags) being accountable
for these problems. External hemorrhoidal veins found under the perianal
skin obviously cannot cause hygiene problems; however, excess skin in the
perianal area can mechanically interfere with cleansing.
Epidemiology
Worldwide, the prevalence of symptomatic hemorrhoids is estimated at
4.4% in the general population. In the United States, up to one third of the
10 million people with hemorrhoids seek medical treatment, resulting in 1.5
million related prescriptions per year.
The number of hemorrhoidectomies performed in US hospitals is declining.
A peak of 117 hemorrhoidectomies per 100,000 people was reached in
1974; this rate declined to 37 hemorrhoidectomies per 100,000 people in
1987. Outpatient and office treatment of hemorrhoids account for some of
this decline.
Patients presenting with hemorrhoidal disease are more frequently white,
from higher socioeconomic status, and from rural areas. There is no known
sex predilection, although men are more likely to seek treatment. However,
pregnancy causes physiologic changes that predispose women to
developing symptomatic hemorrhoids. As the gravid uterus expands, it
compresses the inferior vena cava, causing decreased venous return and
distal engorgement.
External hemorrhoids occur more commonly in young and middle-aged
adults than in older adults. The prevalence of hemorrhoids increases with
age, with a peak in persons aged 45-65 years.
Prognosis
Most hemorrhoids resolve spontaneously or with conservative medical
therapy alone. However, complications can include thrombosis, secondary
infection, ulceration, abscess, and incontinence. The recurrence rate with
nonsurgical techniques is 10-50% over a 5-year period, whereas that of
surgical hemorrhoidectomy is less than 5%.
Regarding complications from surgery, well-trained surgeons should
experience complications in fewer than 5% of cases. Complications include
stenosis, bleeding, infection, recurrence, nonhealing wounds, and fistula
formation. Urinary retention is directly related to the anesthetic technique
used and to the perioperative fluids administered. Limiting fluids and the
routine use of local anesthesia can reduce urinary retention to less than
5%.
Clinical Presentation
SECTIONSHemorrhoids
Overview
o Background
o Anatomy
o Etiology and Pathophysiology
o Epidemiology
o Prognosis
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Media Gallery
References
What to Read Next on Medscape
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Thrombosed External Hemorrhoid Excision
Anal Surgery for Hemorrhoids
Hemorrhoidectomy and Hemorrhoidopexy
Rubber-Band Ligation of Hemorrhoids
Fast Five Quiz: Hemorrhoid Diagnosis and Treatment
NEWS & PERSPECTIVE
Crohn's Disease May Not Be a Contraindication to Hemorrhoidectomy
Medically Managing Opioid-Induced Constipation: A Primer
Neglecting Hemorrhoids Comes at a Cost
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