Hemorrhoids
Hemorrhoids are symptomatic engorgement and prolapse of the normal anal vascular cushions, internal above the dentate line causing painless bright-red bleeding and prolapse and external below the dentate line causing pain, especially with thrombosis. Diagnosis is clinical by inspection and anoscopy, and treatment escalates from fiber and topical measures through office procedures such as rubber band ligation to hemorrhoidectomy for advanced or refractory disease.
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What this article covers
- Overview
Definition: hemorrhoids are the symptomatic engorgement, swelling, and prolapse of the normal vascular cushions of the anal canal, which are submucosal arteriovenous sinusoids that normally support continence.
- Epidemiology
Common condition: symptomatic hemorrhoids are a frequent cause of rectal bleeding and anorectal complaints in adults across primary care and gastroenterology.
- Risk factors
Chronic straining and altered bowel habits: recurrent straining with constipation or diarrhea is the dominant mechanism driving engorgement of the hemorrhoidal plexuses.
- Pathophysiology
Normal function first: the anal vascular cushions are a normal anatomic feature of the anal canal, believed to assist the sphincter mechanism in maintaining continence.
- Clinical features
Painless bright-red bleeding (internal hemorrhoids): blood coating the stool or dripping into the toilet water or on the toilet paper, associated with defecation, the hallmark presentation.
- Differential diagnosis
Anal fissure: a longitudinal mucosal tear causing anorectal pain worsened by defecation and sitting, with painful bleeding on wiping; posterior midline is typical, while a lateral fissure raises…
- Diagnosis
Hemorrhoids are a clinical diagnosis established by inspection and digital rectal examination, with internal disease staged by the four-grade prolapse classification: grade I bleeds without prolapse…
- Management
Start with first-line conservative therapy for all symptomatic hemorrhoids, grade I to II internal and non-thrombosed external disease: psyllium fiber 1 tablespoon (about 3.4 g) in a full glass of…
- Complications
Thrombosis of an external hemorrhoid: acute, severe perianal pain with a tender bluish perianal nodule, the most common acute complication.
- Prognosis
Excellent with staged, symptom-appropriate therapy: most grade I to III internal hemorrhoids resolve or are controlled with conservative measures plus office-based procedures, without need for surgery.
- Prevention
Maintain adequate daily fiber intake: soluble fiber such as psyllium, taken daily, softens stool and reduces straining, the single most effective preventive measure.
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