Hemorrhoids
Wikipedia
September 5th, 2014
Initial management for internal hemorrhoids includes adequate fiber and water intake and avoidance of straining. Office procedures (e.g., rubber-band ligation) are helpful when medical therapy fails; excisional therapies such as hemorrhoidectomy are used for severe disease. Read the new Clinical Practice review article on this topic.
Symptoms related to hemorrhoids are very common in Western and other industrialized societies. Although published estimates of prevalence vary widely, millions of people in the United States are affected yearly.
Clinical Pearls
•How are hemorrhoids categorized?
Hemorrhoids are categorized according to their origin relative to the dentate line, which is typically located about 3 to 4 cm proximal to the anal verge. The line represents the site where the squamous epithelial cells derived from the ectoderm interface with the columnar mucosa cells of endodermal origin. Besides being the basis for categorizing hemorrhoidal complexes as internal (if proximal to the dentate line), external (if distal to the dentate line), or mixed (both proximal and distal), the different embryonic origins lead to distinctly different vascular drainages, epithelialization, and innervation. Tissues that are distal to the dentate line are innervated by somatic nerves and are more sensitive to pain and irritation than those that are located more proximally, which receive sympathetic or parasympathetic visceral innervation.
•What are the typical clinical manifestations of symptomatic hemorrhoids?
The clinical manifestations of symptomatic hemorrhoids vary with the extent of the disease process. Patients who present for diagnosis and treatment typically report hematochezia (approximately 60%), itching (approximately 55%), perianal discomfort (approximately 20%), soiling (approximately 10%), or some combination of these symptoms. The rectal bleeding typically occurs with or immediately after defecation. Blood may be noticed on toilet paper, in toilet water, or, occasionally, staining the underwear. Patients should be queried about their fiber and fluid intake, bowel patterns (including stool frequency), bathroom habits (e.g., reading while seated on the toilet), the need for digital manipulation of prolapsed tissue, and whether there is a history of soiling or incontinence. Other disease processes must be considered. Substantial pain is rare in patients with uncomplicated internal or external hemorrhoids. The presence of severe pain raises the possibility of other conditions, including anal fissure, perirectal or perivaginal infection, abscess, and other inflammatory processes, although severe pain may occur with complications of hemorrhoids (e.g., prolapse with incarceration and ischemia or thrombosis).
Morning Report Questions
Q: What imaging is necessary in a patient with hemorrhoids?
A: Flexible endoscopy is not as successful as anoscopy for examining the anorectum. The decision to perform a more extensive colorectal evaluation should be informed by the patient’s age, presenting signs and symptoms and their duration, and the nature of bleeding. Evaluation of the entire colon is indicated for patients with any of the following: anemia; bleeding that is not typical of hemorrhoids; a change in bowel patterns; a personal history of rectal or colon polyps; a family history of inflammatory bowel disease, colorectal cancer, or other hereditary colorectal diseases in a first-degree relative; or other suspected pathologic pelvic changes that could contribute to the patient’s symptoms. For symptomatic patients younger than 50 years of age who have no risk factors for colonic disease and no evidence of other anorectal abnormalities and in whom examination confirms the presence of uncomplicated disease, hemorrhoid treatment can be administered in lieu of endoscopy or imaging studies. Persistent bleeding or other symptoms after successful local treatment of hemorrhoids is an indication for further evaluation.
Q: How should patients with symptomatic hemorrhoids be treated?
A: All patients should be encouraged to ingest a sufficient amount of insoluble fiber (typically 25 to 35 g per day) and sufficient water to avoid constipation and straining and to limit the time spent on the toilet. A meta-analysis of controlled trials showed that fiber supplementation was associated with significant reductions in the risk of persistent symptoms and the risk of rectal bleeding, although the effects of fiber supplementation on mucosal prolapse, pain, and itching were not significant. Clinical experience indicates that use of topical glucocorticoids, vasoconstrictors (e.g., phenylephrine-based creams or suppositories), or analgesics may provide temporary relief of some symptoms. For patients who do not respond to conservative treatment, a meta-analysis of 18 randomized trials comparing various treatment methods for grade I to III hemorrhoids concluded that rubber-band ligation was more effective than sclerotherapy and that patients who underwent ligation were less likely to need subsequent therapy. Rubber-band ligation was less effective than hemorrhoidectomy but had fewer complications and caused less pain. It therefore is considered appropriate as first-line therapy.
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