Definition
A.Hemorrhoids are clusters of vascular tissues, smooth muscle, and connective tissue of the anal canal. Internal hemorrhoids are above the anorectal line and covered by rectal mucosa. Hemorrhoids can be found at any position of the rectum. Internal hemorrhoids are graded by severity (see Table 14.14).
TABLE 14.14 Severity of Hemorrhoids Used to Guide Treatment Options
B.External hemorrhoids are below the anorectal line, covered by anal skin, and appear as painless, flaccid skin tags (see Figure 14.2).
C.Complications of hemorrhoids include thrombosis, secondary infection, ulceration, abscess, and incontinence.
D.Although rectal bleeding is commonly associated with hemorrhoids, it may be a symptom of other disease processes, such as colorectal cancer (CRC), inflammatory bowel disease (IBD), other colitides, diverticular disease, and angiodysplasia.
Incidence
A.The incidence of hemorrhoids is estimated at 4.4% worldwide. Patients tend to present after utilization and failure of over-the-counter (OTC) treatments. Hemorrhoids are common in people between 45 and 65 years of age. They are uncommon in people younger than age 20 except secondary to pregnancy.
Pathogenesis
A.External hemorrhoids develop from the ectoderm and are covered by squamous epithelium.
B.Internal hemorrhoids develop from the embryonic endoderm and are lined with columnar epithelium of anal mucosa.
C.Mechanism is unknown. Prolapse may be initiated by shearing force from passage of large firm stool, by increased venous pressure from portal hypertension or pregnancy, or by straining that occurs with lifting or defecation.
Predisposing Factors
A.Pressure and straining with stool associated with constipation.
B.Chronic diarrhea.
C.Pelvic congestion.
D.Poor pelvic musculature.
E.Pregnancy.
F.Episiotomy.
G.Portal hypertension, cirrhosis.
H.Low-fiber diet.
I.Sedentary jobs.
J.Loss of muscle tone due to advanced age.
K.Anal intercourse.
L.Obesity.
M.Colon malignancy.
N.Rectal surgery.
O.Inflammatory bowel disease.
Common Complaints
A.Cardinal features:
1.Bleeding: Painless, bright red bleeding with defecation (internal).
FIGURE 14.2Internal and external hemorrhoids. A. Internal hemorrhoid: Covered by a thin sheet of tissue called mucous membrane, an internal hemorrhoid bulges into the rectal opening and may sink a bit during bowel movements. B. External hemorrhoid: Covered by skin, an external hemorrhoid protrudes from the rectum.
2.Anal pruritus.
3.Prolapse.
4.Pain related to thrombosis.
Other Signs and Symptoms
A.Visible prolapsed mass.
B.Incomplete defecation.
C.Leakage of feces (internal hemorrhoids).
D.Excessive moisture.
E.Weakness or fatigue, with anemia.
Subjective Data
A.Review onset and duration of symptoms, especially the history of rectal bleeding, prolapse, issues of hygiene, and pain.
B.Review the quantity, color, and timing of any rectal bleeding (bright red, dripping, streaks on toilet paper).
C.Review the patient’s history of hemorrhoids and treatments, including surgery.
D.Ask the patient about recent pregnancy, liver disease, and constipation.
E.Inquire about the patient’s job and level of daily activity.
F.Review the patient’s sexual practices for anal intercourse.
G.Review the patient’s dietary history for fluid intake and sources/amount of fiber.
H.Ask about bowel habits, including frequency, consistency, and ease of evacuation.
I.Review a detailed family history, with emphasis on intestinal disease.
J.Review patient’s history of coagulation and immune status.
Physical Examination
A.Check temperature (if indicated), pulse, respirations, and blood pressure (BP). Measure and weight to calculate body mass index (BMI).
B.Inspect:
1.Observation of rectal area for skin tags, prolapse, irritation, fissures, and condyloma:
a.Internal hemorrhoids are usually not visible unless prolapsed.
b.External hemorrhoids protrude with straining or standing.
c.In order to observe and evaluate hemorrhoids/prolapse, ask the patient to strain down like they are having a bowel movement.
2.Using anoscopy: Visualize internal rectum for hemorrhoids, masses, or fissures (approximately 20% have concomitant anal fissures).
C.Palpate:
1.Palpate abdomen for masses and tenderness.
2.Internal hemorrhoids are usually not palpable unless thrombosed.
3.Perform digital rectal examination. (Topical anesthetics may be needed to reduce discomfort from the examination.)
a.Evaluate rectal tone.
b.Palpate the prostate.
4.Neurologic examination:
a.Evaluate the presence of an anal wink (reflexive contraction of the external anal sphincter upon stroking of the skin).
Diagnostic Tests
Full evaluation of the large bowel with colonoscopy is recommended for patients with significant abdominal symptoms, weight loss, change in bowel habits, age older than 50, or other risk factors for colonic malignancy.