Hemorrhoids

swollen blood vessels in the lower rectum.

Etiology
- Decreased venous return
- straining and constipation
- pregnancy
- portal hypertension
-varices
- Abnormal swelling of the anal cushions -> dilatation and engorgement of arteriovenous
plexuses. Which leads to stretching of suspensory muscle and prolapse of rectal tissue to anal
canal.
Risk Factors

low-fiber diets
pregnancy
sitting on a toilet while reading
aging
lack of erect posture
familial tendency
chronic diarrhea

colon malignancy
obesity
loss of rectal muscle tone
anal intercourse
IBD (ulcerative colitis, Crohn Disease)

Classification
- External Hemorrhoids
develop from ectoderm and are covered by squamous epithelium
Innervated by cutaneous nerves that supply perianal area,
including pudendal nerve and sacral plexus.
- Internal Hemorrhoids
derived from embryonic endoderm and lined with columnar epithelium
of anal mucosa. They are not supplied by somatic sensory nerves and therefore
cannot cause pain. At level of dentate line, internal hemorrhoids
are anchored to the underlying muscle by the mucosal suspensory
ligament.
Sign and Symptoms
Internal hemorrhoids typically do not cause pain, but rather, bright red bleeding per rectum,
mucous discharge, and a sense of rectal fullness or discomfort. Infrequently internal
hemorrhoids will prolapse into the anal canal, incarcerate, thrombose, and necrose. In this
instance, patients may complain of pain.
Visual inspection of the perineum may reveal a normal-appearing perineum, edema near the
involved hemorrhoid, a prolapsed hemorrhoid, or an edematous, gangrenous, incarcerated
hemorrhoid. The perineum may be macerated from chronic mucous discharge, the resulting
moisture, and local irritation. Anoscopy may reveal tissue with evidence of chronic vascular
dilatation, friability, mobility, and squamous metaplasia.
External hemorrhoids may develop suddenly from acute intravascular thrombus. This is
associated with acute onset of extreme perianal pain. The pain usually peaks within 48 hours.
Repeated episodes of thrombosis may lead to enlargement of the overlying skin, which is seen as
a skin tag on physical examination. The acutely thrombosed external hemorrhoid is seen as a
purplish, edematous, tense subcutaneous perianal mass that is quite tender (perianal mass).
The thrombus occasionally may cause ischemia and necrosis of the overlying skin resulting in
bleeding.

Complications
thrombosis, secondary infection, ulceration, abscess, incontinence, stenosis, bleeding, infection,
nonhealing wounds, pain, mucous discharge, necrosis
Differential Diagnosis
- Painless bleeding must be distinguished from rectal bleeding from colorectal malignancy,
adenomatous polyps, IBD or diverticular disease.
- Painful bleeding ulcer or fissure
- Straining at stool may be secondary to obstructed defecation.
- Rectal prolapse
- Condylomata acuminata