Diagnosis and Management of Symptomatic Hemorrhoids

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Pathophysiology

Hemorrhoids are cushions of highly vascular tissue found within the submucosal space and are considered part of the normal anatomy of the anal canal. The anal canal contains 3 main cushions that are found in the left lateral, right anterior, and right posterior positions. Within these hemorrhoidal cushions, blood vessels, elastic tissue, connective tissue, and smooth muscle are found.3, 5, 6 Together, these tissues contribute to 15% to 20% of the resting pressure within the anal canal.3 Each

Classification

There are 2 types of hemorrhoids, external and internal, which are classified anatomically based on their location relative to the dentate line (Fig. 1). External hemorrhoids are located distal to the dentate line and are covered by modified squamous epithelium (anoderm), which is richly innervated tissue, making external hemorrhoids extremely painful on thrombosis.8 Internal hemorrhoids are located proximal to the dentate line and are covered by columnar epithelium. The overlying columnar

Differential diagnosis

Often, patients are referred to a surgeon already diagnosed with hemorrhoids or “piles”, but it is still important to rule out other causes of similar symptoms. The differential diagnosis of hemorrhoids includes anal fissure, perirectal abscess, anal fistula, anal stenosis, malignancy, inflammatory bowel disease (IBD, Crohn's disease and ulcerative colitis), anal condyloma, pruritus ani, rectal prolapse, hypertrophied anal papilla, and skin tags.3 Although not all-inclusive, this list does

Clinical presentation

Like all medical problems, it is important to take a thorough history and to complete a physical examination to confirm a diagnosis of hemorrhoids. Internal hemorrhoids typically cause painless bleeding, tissue protrusion, mucous discharge, or the feeling of incomplete evacuation.3, 4, 11 Symptoms of external hemorrhoids tend to be different, including anal discomfort with engorgement, pain with thrombosis, and itching caused by difficult perianal hygiene due to the presence of skin tags.3, 4

Treatment

The treatment of symptomatic hemorrhoids varies and ranges from conservative therapy involving dietary and lifestyle changes to use of various pharmacological agents and creams, office-based nonoperative procedures, and operative hemorrhoidectomy.

Dietary/Lifestyle Changes

Whether treating symptomatic hemorrhoids with medical or operative management, several dietary and lifestyle changes should be encouraged, to help prevent the recurrence of symptoms. The ultimate treatment goal should be the maintenance of soft, bulked stools that pass easily without straining at the time of defecation. A diet high in fiber, approximately 20 to 35 g/d, or intake of fiber supplements, such as psyllium (Konsyl), methylcellulose (Citrucel), or calcium polycarbophil (FiberCon), is

Rubber Band Ligation

Rubber band ligation (RBL) is a common procedure for treatment of first-, second-, or third-degree hemorrhoids, performed in the office without administration of local anesthesia and without preparation of the bowel with an enema. Barron15 initially described this technique in 1963 with successful results in the 50 patients enrolled in the original study. This procedure is performed by placing a rubber band on the mucosa of the hemorrhoid approximately 1 cm or more above the dentate line (Fig. 3

Open/Closed Excision

Historically, numerous procedures have been described for the surgical treatment of symptomatic hemorrhoids, including those by Buie, Fansler, Ferguson, Milligan-Morgan, Parks, Salmon, and Whitehead.1 Operative hemorrhoidectomy is indicated in the treatment of combined internal and external hemorrhoids or third- and fourth-degree hemorrhoids, especially in patients who are unresponsive to other methods of treatment or those with extensive disease.2, 3 The need for operative intervention is

Postoperative complications

Surgeons learn over time when it is appropriate to recommend an operation. This is particularly true in the management of hemorrhoidal disease. Rarely are hemorrhoids life-threatening; more commonly, symptoms represent an excessive nuisance. Yet, there are definitely certain patients who benefit from a surgical excision. By understanding the potential operative risks, one can weigh the risks of surgery and guide the patient towards an appropriate treatment option. The following potential

Hemorrhoid Strangulation/Crisis

When a patient presents with a severe hemorrhoid attack, it is perceived unquestionably as a crisis (Fig. 7). When considering treatment options, determining whether there is loss of tissue viability is a key step. At times, this can be difficult based on a limited examination secondary to severe pain and tissue edema. Considering other clues, such as fever, tachycardia, foul odor, and leukocytosis is important. If necrotic tissue is encountered, urgent excision and debridement must be

Summary

Symptomatic hemorrhoidal disease is extremely common, and a complete understanding of the normal anatomy and physiology of the anorectum facilitates management recommendations. With a firm diagnosis in hand, treatment options include topical applications, office-based procedures, and operative interventions. Postprocedure complication rates tend to be low, and durable long-term results are offered. With all available options on hand, the surgeon can confidently select the proper treatment for

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