Hemorrhoids (piles): Pathophysiology, Clinical Features, Diagnosis, Prevention & Treatment

Hemorrhoids are masses of dilated blood vessels that lie beneath the lining of skin in the anal canal. It is the perianal varicose vein or the dilated portion of the vein in the anal canal.

Hemorrhoids are classified into two types:

  1. Internal and external hemorrhoids

Internal hemorrhoids: it occurs above the anal sphincter
External hemorrhoids: it occurs below the anal sphincter

Incidence
Hemorrhoids are a common disorder affecting both men and women of any age. The incidence is increased between 20-50 years of age.

Aetiological factor

The exact cause remains unclear or unknown but contributing factors are:

  • Hereditary (rare)
  • Congenital weakness of the vein wall or
  • Abnormally large arterial supply to the rectal plexus
  • Recurrent constipation/ diarrhea
  • Staining accompany: constipation
  • Persistent elevation in intraluminal pressure
  • Pregnancy, obesity, heavy lifting
  • Congestive heart failure and chronic liver disease resulting portal hypertension (increase venous pressure)
  • The sedentary lifestyle involving long periods of sitting or standing
  • Aging, prostate enlargement in males
  • Excessive use of enemas or laxatives

Pathophysiology

Internal hemorrhoids
Hemorrhoids are developed as a result of shearing force during defecation or straining during a bowel movement increases intrabdominal and hemorrhoidal venous pressure. These force or pressure damage the supporting muscles resulting weaken and dilated anal canal. When the rectal ampulla is filled with stool, venous obstruction is believed to occur, as a result of the repeated and prolonged increase in thin pressure, hemorrhoidal veins become permanently dilated. These causes impaired blood flow through the vein of hemorrhoidal plexus. As a result of distension thrombosis and the bleeding also may occur.

External hemorrhoids
Varicosities of veins draining the territory of inferior rectal arteries which are branches of internal pudendal artery itching due to skin irritation prone to thrombosis, of vein rupture and /or a blood clot develops. It is thrombosis hemorrhoids.

Clinical features

Internal hemorrhoids

  • Asymptomatic
  • Painless, intermittent bleeding during defecation
  • When internal hemorrhoids become constricted patient may report pain
  • When it become prolapsed and strangulated there is a pain

External hemorrhoids

  • Visible bluish skin covered lumps in the anal region
  • If blood clots in external hemorrhoids become inflamed oedematous and painful
  • Intermittent pain, pain on palpation, itching, and burning
  • Rectal bleeding associated with defecation (patient may complain)
  • Extremely itching around the anus
  • Irritation and pain around the anus area
  • Fecal leakage or incontinence
  • Painful bowel movements
  • Blood on the tissue after having a bowel movement

Diagnosis

The physical examination typically diagnoses hemorrhoids (piles). A visual examination of the anus and surrounding area help to diagnose external or prolapsed hemorrhoids.

Internal hemorrhoids
It originates above the dentate line. They were classified in 1985 into four grades based on the degree of prolapse.

  • Grade I: No prolapse, just prominent blood vessels
  • II: Prolapse upon bearing down, but a spontaneous reduction
  • III: Prolapse upon bearing down requiring manual reduction
  • IV: Prolapse with an inability to be manually reduced

External hemorrhoids
It occurs below the dentate line.

  • Proctoscopy: to confirm internal hemorrhoids (visual inspection of an anus, digital palpation with a gloved lubricated finger)
  • Lab investigation: CBC including electrolytes
  • Sigmoidoscopy or colonoscopy to rule out other cause of disease

Management

Local or conservative management

  • High fiber diet and increased fluid intake
  • Warm sitz  bath given several times or day to relief pain
  • Application of cold and hot (topical nitroglycerin may also be used)
  • A stool softener is given to decrease the irritation of hemorrhoids
  • Analgesic ointment application (with hydrocortisone) to relieve pain and reduce edema

Surgical management

  • Sclerotherapy: The injection of a sclerosing agent performs sclerotherapy. It causes the formation of scar tissue between around the veins. This produces an inflammatory reaction that leads to thrombosis and fibrosis causing shrinkage of pile mass.
  • Ligation (rubber band): hemorrhoid is ligated with a rubber band which becomes necrotic and slough off due to impaired circulation.
  • Cryosurgery: freezing of hemorrhoidal tissue leads to necrosis and sloughing of hemorrhoids
  • Infrared coagulation: infrared rays uses to burn the hemorrhoid tissue
  • Laser treatment: the hemorrhoids is burned off with a very thin beam of light in which very high energies are concentrated (laser). There is minimal bleeding although the procedure causes some pain.
  • Bipolar diathermy: heat production of high-frequency electric current passed between two electrodes placed on the patient skin.
  • Hemorrhoidectomy: the vein is excised and the area either is left open to heal by granulation or is closed with sutures. The open method is very painful but has a high rate of success. The suture method, although for less painful is more likely to cause infection and result in poor healing.

Home remedies

  • Maintaining good hygiene by cleaning anus area with warm water during a shower or bath every day.
  • Avoid using dry or rough toilet paper when wiping after a bowel movement
  • Using a cold compress on anus can help to reduce hemorrhoid swelling

Complication

  • Bleeding, thrombosis and hemorrhoidal strangulation
  • Iron deficiency anemia from severe bleeding during defecation
  • Post-surgery hemorrhage, infection, stricture formation and the lesion heals

Hemorrhage may occur immediately after surgery or about 10 days later as a result of sloughing of tissue. Also, bleeding may not be evident because it can occur into the rectum without being passed immediately.

Prevention

  • To prevent or avoid worsening hemorrhoids, avoid straining during a bowel movement also try to increase the fluid intake which helps the stool from hardening.
  • Increase fiber diets help to prevent constipation.
  • Exercise regularly to prevent becoming constipated
  • don’t sit for long periods, especially on hard surfaces like concrete or tile
  • spending less time attempting to defecate
  • losing weight for overweight persons
  • avoiding heavy lifting

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