Hemorrhoids are varicosities in the superior or inferior hemorrhoidal venous plexus; they're commonly painful. Dilation and enlargement of the superior plexus produce mucus-covered, internal hemorrhoids that bulge into the rectal lumen and may prolapse during defecation. Dilation and enlargement of the inferior plexus produce skin-covered, external hemorrhoids that may protrude from the rectum. External hemorrhoids are more likely to be thrombotic than internal hemorrhoids. Generally, the incidence of hemorrhoids peaks between ages 20 and 50 and affects both sexes.
Hemorrhoids can develop from any increase in pressure in the veins in the lower rectum. Common sources of pressure include:
It's also possible to inherit a tendency to develop hemorrhoids.
Signs and Symptoms
Typically, the patient notices and reports intermittent rectal bleeding after defecation. He may report bright red blood on his stools or toilet paper, a sign that the fragile mucosa covering the hemorrhoid was injured during defecation. He also may complain of anal itching (the result of poor anal hygiene) or describe a vague feeling of anal discomfort when bleeding occurs.
If the hemorrhoids are thrombosed, the patient usually complains of rectal pain, which may be accompanied by anal pruritus and mucus discharge. If external hemorrhoids are thrombosed, he may be aware of a large subcutaneous lump in the anal area.
Inspection of the anal area confirms the presence of external hemorrhoids. If the external hemorrhoids are thrombosed, they appear on inspection as blue swellings at the anus. Although internal hemorrhoids usually aren't seen on inspection, they're obvious if they have prolapsed.
Palpation reveals anal tenderness. Digital rectal examination may disclose internal hemorrhoids.
Anoscopy and flexible sigmoidoscopy are used to confirm internal hemorrhoids and rule out other possible causes of symptoms, such as rectal polyps and anal fistulas.
Hemorrhoids generally require only conservative treatment designed to ease pain, combat swelling and congestion, and regulate bowel habits. To reduce local pain and swelling, local anesthetic agents (lotions, creams, or suppositories), astringents, or cold compresses may be applied, followed by warm sitz baths or thermal packs. A steroid preparation, such as hydrocortisone, can relieve itching or inflammation.
Stool softeners help prevent straining during defecation. If the patient has a mildly prolapsed internal hemorrhoid, manual reduction may be attempted. Rarely, the patient with chronic, profuse bleeding may require a blood transfusion.
Several outpatient procedures may be used to treat hemorrhoids. A sclerosing solution may be injected to induce scar formation and decrease prolapse. Elastic band ligation is even more effective than sclerotherapy.
Hemorrhoidectomy, still the most effective method with less need for further therapy, is indicated for patients with severe bleeding, intolerable pain, pruritus, and large prolapse. This surgery, by which the hemorrhoid is removed through cauterization or excision, can be performed on an outpatient basis.
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