Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term hemorrhoid is often used to refer to the disease. The signs and symptoms of hemorrhoids depend on the type present. Internal hemorrhoids often result in painless, bright red rectal bleeding when defecating. External hemorrhoids often result in pain and swelling in the area of the anus. If bleeding occurs, it is usually darker. Symptoms frequently get better after a few days. A skin tag may remain after the healing of an external hemorrhoid. While the exact cause of hemorrhoids remains unknown, a number of factors that increase pressure in the abdomen are believed to be involved. This may include constipation, diarrhea, and sitting on the toilet for long periods. Hemorrhoids are also more common during pregnancy. Diagnosis is made by looking at the area. Many people incorrectly refer to any symptom occurring around the anal area as hemorrhoids, and serious causes of the symptoms should be ruled out. Colonoscopy or sigmoidoscopy is reasonable to confirm the diagnosis and rule out more serious causes. Often, no specific treatment is needed and hemorrhoids that do not cause symptoms do not require treatment. Initial measures consist of increasing fiber intake, drinking fluids to maintain hydration, NSAIDs to help with pain, and rest. Medicated creams may be applied to the area, but their effectiveness is poorly supported by evidence. A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management. Hemorrhoidal artery embolization (HAE) is a safe and effective minimally invasive procedure that can be performed and is typically better tolerated than traditional therapies. Laser hemorrhoidoplasty (LHP) is a minimally invasive laser therapy for treating hemorrhoids. According to specific clinical practice recommendations, symptomatic grade 2 and grade 3 hemorrhoids are standard indications for laser hemorrhoidoplasty as a single intervention. Systematic reviews and meta-analyses including randomized controlled trials have reported that LHP is associated with improved perioperative and short-term postoperative outcomes compared with conventional hemorrhoidectomy, including less postoperative pain and faster recovery. Surgery is reserved for those who fail to improve following these measures. Approximately 50% to 66% of people have problems with hemorrhoids at some point in their lives. Males and females are both affected with about equal frequency. Hemorrhoids affect people most often between 45 and 65 years of age, and they are more common among the wealthy, although this may reflect differences in healthcare access rather than true prevalence. Outcomes are usually good. The first known mention of the disease is from a 1700 BC Egyptian papyrus.
Signs and symptoms
In about 40% of people with pathological hemorrhoids, there are no significant symptoms. Internal and external hemorrhoids may present differently; however, many people may have a combination of the two. Bleeding enough to cause anemia is rare, and life-threatening bleeding is even more uncommon. Many people feel embarrassed when facing the problem and often seek medical care only when the case is advanced.
External If not thrombosed, external hemorrhoids may cause few problems. However, when thrombosed, hemorrhoids may be very painful. Nevertheless, this pain typically resolves in two to three days. The swelling may, however, take a few weeks to disappear. A skin tag may remain after healing. If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus.
Internal Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement. The blood typically covers the stool, is on the toilet paper, or drips into the toilet bowl. The stool itself is usually normally colored. Blood mixed in with the stool is usually due to another cause of bleeding in the gut. Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus, itchiness, and fecal incontinence. Internal hemorrhoids are usually painful only if they become thrombosed or necrotic.
Causes The exact cause of symptomatic hemorrhoids is unknown. A number of factors are believed to play a role, including irregular bowel habits (constipation or diarrhea), lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining, ascites, an intra-abdominal mass, or pregnancy), genetics, an absence of valves within the hemorrhoidal veins, and aging. Other factors believed to increase risk include obesity, a chronic cough, and pelvic floor dysfunction. Squatting while defecating may also increase the risk of severe hemorrhoids. Evidence for these associations, however, is poor. Being a receptive partner in anal intercourse has been listed as a cause. During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures. Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery. A personal history of hemorrhoids or anal fissures, constipation, prolonged straining during delivery, and delivering a larger baby (weighing over 3,800 grams) are risk factors for hemorrhoids during pregnancy and in the post-partum period.
Pathophysiology
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