Hemorrhoid

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Hemorrhoids Classification & external resources
Schematic demonstrating the anatomy of hemorrhoids.
ICD-10	I84.
ICD-9	455
MedlinePlus	000292
eMedicine	med/2821

Hemorrhoids (AmE), haemorrhoids (BrE), emerods, or piles are varicosities or swelling and inflammation of veins in the rectum and anus.

Hemorrhoids are actually the anatomical term for "\'cushions of tissue filled with blood vessels at the junction of the rectum and the anus."http://0-www.nlm.nih.gov.catalog.llu.edu/medlineplus/ency/presentations/100026_1.htm However, the term has come into common usage to indicate the condition described herein. Perianal hematoma are sometimes misdiagnosed and mislabled as hemorrhoids, when in fact they have different causes and treatmentshttp://www.medbroadcast.com/channel_section_details.asp?text_id=1450&channel_id=1017&relation_id=5225.

Contents 1 Prevalence 2 Causes 2.1 Symptoms 2.2 Food 3 Types of hemorrhoids 3.1 By degree of prolapse 4 Prevention 4.1 Use of squat toilets 5 Examination 6 Treatments 6.1 Natural treatments 6.2 Surgical /non medicinal treatments 6.3 Diseases with similar symptoms 7 References 8 See also 9 External links

Prevalence

This article or section deals primarily with the United States and does not represent a worldwide view of the subject. Please improve this article or discuss the issue on the talk page.

Hemorrhoids are common. In the USA, the prevalence is about 4.4%.Hemorrhoid at eMedicineJohanson JF, Sonnenberg A (1990). "The prevalence of hemorrhoids and chronic constipation. An epidemiologic study". Gastroenterology 98 (2): 380–6. PMID 2295392.  It is estimated that approximately one half of all Americans have had this condition by the age of 50, and that 50% to 85% of the world\'s population will be affected by hemorrhoids at some time in their life.^{[citation needed]} However, only a small number seek medical treatment. Annually, only about 500,000 in the U.S. are medically treated for massive hemorrhage, with 10 to 20% of them requiring surgeries.

According to a British medical journal of 1972 hemorrhoids "are common in economically developed communities, rare in developing countries, and almost unknown in tribal communities, where the influence of Western countries is slight."Burkitt, DP, Varicose Veins, Deep Vein Thrombosis, and Haemorrhoids: Epidemiology and Suggested Aetiology,Br Med J. 1972 June 3; 2(5813): 556–561.link to article

Causes

The general cause of hemorrhoids is excessive stress and pressure on rectal veins.

Some people have a genetic predisposition to weak rectal vein walls and/or valves.

Increased straining during bowel movements, by constipation or diarrhea, may lead to hemorrhoids. Harms R (Nov 3, 2007). Hemorrhoids during pregnancy: Treatment options. MayoClinic. Retrieved on 2007-11-28. It is thus a common condition due to constipation caused by water retention in women experiencing premenstrual syndrome or menstruation.

Hypertension, particularly portal hypertension, can also cause hemorrhoids because of the connections between the portal vein and the vena cava which occur in the rectal wall -- known as portocaval anastomoses.Causes of Hemorrhoids. Mayo Clinic (Nov 28, 2006). Retrieved on 2007-12-07.

Obesity can be a factor by increasing rectal vein pressure. Sitting for prolonged periods of time can cause hemorrhoids. Poor muscle tone or poor posture can result in too much pressure on the rectal veins.

Pregnancy causes hypertension and increases strain during bowel movements, so hemorrhoids are often associated with pregnancy.

Anal sex without sufficent lubricant can also cause excessive strain to rectal veins, and is in fact one of the most common causes of hemorrhoids amongst otherwise healthy young adults.

Excessive consumption of alcohol or caffeine can cause hemorrhoids.Burney RE (November 2005). Hemorrhoids. University of Michigan Health System. Retrieved on 2007-11-28. Both can cause diarrhea. Note that caffeine ingestion increases blood pressure transiently, but is not thought to cause chronic hypertension. Alcohol can also cause alcoholic liver disease leading to portal hypertension.

Symptoms

There is some overlap with symptoms of rectal and anal carcinoma; always consult a doctor.

People with Hemorrhoids may experience the following symptoms:

* Pruritis Ani (itchiness around the anal canal).
* Bleeding, usually bright red, ranging from light staining of toilet paper to profuse hemorrhaging.
* Mucous discharge.
* Pain, mainly in thrombosed hemorrhoids.
* Palpable Lump/mass in prolapsed hemorrhoids (grade 2 to 4).

Food

This section does not cite any references or sources. (September 2006) Please improve this section by adding citations to reliable sources. Unverifiable material may be challenged and removed.

Insufficient liquid can cause a hard stool, or even chronic constipation, which can lead to hemorrhoidal irritation. An excess of lactic acid in the stool, a product of excessive consumption of dairy products such as cheese, can cause irritation; reducing such consumption can bring relief. Vitamin E deficiency is also a common cause.

Eating fruit helps avoid conditions that lead to hemorrhoids.

Food considered "probiotic", such as yogurt with active culture, may help keep the gut functioning normally and thus prevent flare-ups.

Types of hemorrhoids

Direct view of hemorrhoid seen on sigmoidoscopy

• (I84.3-I84.5) External hemorrhoids are those that occur outside of the anal verge (the distal end of the anal canal). They are sometimes painful, and can be accompanied by swelling and irritation. Itching, although often thought to be a symptom from external hemorrhoids, is more commonly due to skin irritation.
  • (I84.3) External hemorrhoids are prone to thrombosis: if the vein ruptures and a blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid.E. Gojlan, Pathology, 2nd ed. Mosby Elsevier, Rapid Review series.
• (I84.0-I84.2) Internal hemorrhoids are those that occur inside the rectum. As this area lacks pain receptors, internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated.
• (I84.1) Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids:
  • Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside the anus.
  • If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid.

By degree of prolapse

The most common grading system was developed by Banov:Banov L, Knoepp LF, Erdman LH, Alia RT (1985). "Management of hemorrhoidal disease". J S C Med Assoc 81 (7): 398–401. PMID 3861909. 

• Grading of Internal Hemorrhoids
  • Grade I: The hemorrhoids do not prolapse.
  • Grade II: The hemorrhoids prolapse upon defecation but spontaneously reduce.
  • Grade III: The hemorrhoids prolapse upon defecation, but must be manually reduced.
  • Grade IV: The hemorrhoids are prolapsed and cannot be manually reduced.

Prevention

This section does not cite any references or sources. (September 2006) Please improve this section by adding citations to reliable sources. Unverifiable material may be challenged and removed.

Prevention of hemorrhoids includes drinking more fluids, eating more dietary fiber (such as fiber supplements, fruits and vegetables, and cereals high in fiber), exercising, practicing better posture, and reducing bowel movement strain and time. Hemorrhoid sufferers should avoid using laxatives and should strictly limit time straining during bowel movement. Wearing tight clothing and underwear will also contribute to irritation and poor muscle tone in the region and promote hemorrhoid development. Some sufferers report a more comfortable experience without underwear or wearing only very lightweight underwear.

Women who notice they have painful stools around the time of menstruation would be well-advised to begin taking extra dietary fiber and fluids a couple days prior to that time.

Fluids emitted by the intestinal tract may contain irritants that may increase the fissures associated with hemorrhoids. Washing the anus with cool water and soap may reduce the swelling and increase blood supply for quicker healing and may remove irritating fluid.

Kegel exercises for the pelvic floor may also prove helpful.

Many people do not get a sufficient supply of dietary fiber (20 to 25 grams daily) and small changes in a person\'s daily diet can help tremendously in both prevention and treatment of hemorrhoids.

Use of squat toilets

Based on their very low incidence in the developing world, where people squat for bodily functions, hemorrhoids have been attributed to the use of the unnatural "sitting" toilet.Sikirov BA (1989). "Primary constipation: an underlying mechanism". Med. Hypotheses 28 (2): 71–3. PMID 2927355. Sikirov D (2003). "Comparison of straining during defecation in three positions: results and implications for human health". Dig. Dis. Sci. 48 (7): 1201–5. PMID 12870773.  In 1987, an Israeli physician, Dr. Berko Sikirov, published a study testing this hypothesis by having hemorrhoid sufferers convert to squat toilets.Sikirov BA (1987). "Management of hemorrhoids: a new approach". Isr. J. Med. Sci. 23 (4): 284–6. PMID 3623887.  Eighteen of the 20 patients were completely relieved of their symptoms (pain and bleeding) with no recurrence, even 30 months after completion of the study. This chart summarizes the results.

No follow-up studies have ever been published. The American Society of Colon & Rectal Surgeons is silent regarding the therapeutic value of squatting.

Examination

Endoscopic image of internal hemorrhoids seen on retroflexion of the flexible sigmoidoscope at the ano-rectal junction

After visual examination of the anus and surrounding area for external or prolapsed hemorrhoids, a doctor would conduct a digital examination. In addition to probing for hemorrhoidal bulges, a doctor would also look for indications of rectal tumor or polyp, enlarged prostate and abscesses.

Visual confirmation of hemorrhoids can be done by doing an anoscopy, using a medical device called an anoscope. This device is basically a hollow tube with a light attached at one end that allows the doctor to see the internal hemorrhoids, as well as polyps in the rectum.

If warranted, more detailed examinations, such as sigmoidoscopy and colonoscopy can be performed. In sigmoidoscopy, the last 60cm of the colon and rectum are examined whereas in colonoscopy the entire bowel is examined.

A pathologist will look for dilated vascular spaces which exhibit thrombosis and recanalization.

Treatments

Treatments for hemorrhoids vary in their cost, risk, and effectiveness. Different cultures and individuals approach treatment differently. Some of the treatments used are listed here in increasing order of intrusiveness and cost.

For many people, hemorrhoids are mild and temporary conditions that heal spontaneously or by the same measures recommended for prevention. There is no medicine that will cure hemorrhoids, but local treatments such as warm sitz baths, using a bidet, extendable showerhead, cold compress, or topical analgesic (such as Nupercainal), can provide temporary relief. Especially in the case of external hemorrhoids with a visible lump of small size, the condition can be improved with warm bath causing the vessels around rectal region to be relaxed. Consistent use of medicated creams during the early stages of a hemorrhoid flare-up will also provide relief and may stave off further development and irritation. However, creams containing steroid preparations weaken the skin and may contribute to further flare-ups. Keep the area clean and dry, with some lubrication provided by hemorrhoidal creams or a lubricant. Ointment or suppositories such as Proctosedyl http://www.netdoctor.co.uk/medicines/100002157.htmlhttp://www.medbroadcast.com/drug_info_details.asp?brand_name_id=946 and Faktu http://www.vghks.gov.tw/ph/%E8%99%95%E6%96%B9%E9%9B%86/drug/faktu.htm can also relieve the symptoms.

Natural treatments

Some people claim to have successfully applied natural procedures for treatment or reversal of chronic conditions. These procedures largely echo the prevention measures. However, self-care measures, including herbal or "natural" remedies, should not be undertaken without medical consent to avoid possible drug interactions. They include:

• Reducing regional pressure in such ways as improving posture and muscle tone, or in severe cases, undergoing a profound psychophysical reeducation, by a method such as the Alexander Technique.
• Taking herbs and dietary supplements that strengthen vein walls, such as Butcher\'s Broom, Horse-chestnut, bromelain, and Japanese Pagoda Tree extracts. Drinking 99% pure aloe juice can also relieve itching and swelling.
• Topical application of natural astringents and soothing agents, such as Witch hazel (astringent), Cranesbill, Aloe vera, and honey.
• Drinking chamomile tea several times a day.
• Eating fiber-rich bulking agents such as plantain and Psyllium seed husks to help create a softer stool that is easier to pass, to lessen the irritation of existing hemorrhoids.
• Using the squatting position for bowel movements.Christine Dimmer, Brian Martin, Noeline Reeves and Frances Sullivan (October 1996). "Squatting for the Prevention of Hemorrhoids". Townsend Letter for Doctors & Patients (159): 66-70. 
• For sufferers of hemorrhoids caused by poor vein circulation (coupled with varicose veins in lower extremities and/or varicocele), sleeping overnight with raised legs helps reduce or completely eliminate especially external hemorrhoids. A 12-inch by 24-inch foam wedge is available in most medical supplies stores for less than $50. It should be covered with a zippered, removable, 50% cotton muslin cover.^{[citation needed]}

The combination of internal and external remedies is particularly recommended, e.g. Witch-hazel suppositories combined with frequent cups of strong chamomile tea.K. Kraft and C. Hobbs, Pocket Guide to Herbal Medicine. New York: Thieme.

Dietary supplements can help treat and prevent many complications of hemorrhoids, and natural botanicals such as Butchers Broom, Horse-chestnut, and bioflavonoids can be an effective addition to hemorrhoid treatment.MacKay D (2001). "Hemorrhoids and varicose veins: a review of treatment options" (PDF). Altern Med Rev 6 (2): 126–40. PMID 11302778. 

Butcher\'s Broom extract, or Ruscus aculeatus, contains ruscogenins that have anti-inflammatory and vasoconstrictor effects that help tighten and strengthen veins. Butcher’s Broom has traditionally been used to treat venous problems including hemorrhoids and varicose veins. (1998) in Pizzorno JE and Murray MT, eds.: Encyclopedia of Natural Medicine, revised 2nd edition, CA: Prima Publishing, 829. Rudofsky G (1989). "[Improving venous tone and capillary sealing. Effect of a combination of Ruscus extract and hesperidine methyl chalcone in healthy probands in heat stress]" (in German). Fortschr. Med. 107 (19): 52, 55–8. PMID 2668140. Cappelli R, Nicora M, Di Perri T (1988). "Use of extract of Ruscus aculeatus in venous disease in the lower limbs". Drugs Exp Clin Res 14 (4): 277–83. PMID 3048951. 

Horse-chestnut extract, or Aesculus hippocastanum, contains a saponin known as aescin, that has anti-inflammatory, anti-edema, and venotonic actions. Aescin improves tone in vein walls, thereby strengthening the support structure of the vein. Double blind studies have shown that supplementation with Horse-chestnut helps relieve the pain and swelling associated with chronic venous insufficiency.Pittler MH, Ernst E (1998). "Horse-chestnut seed extract for chronic venous insufficiency. A criteria-based systematic review". Arch Dermatol 134 (11): 1356–60. PMID 9828868. Diehm C, Trampisch HJ, Lange S, Schmidt C (1996). "Comparison of leg compression stocking and oral Horse-chestnut seed extract therapy in patients with chronic venous insufficiency". Lancet 347 (8997): 292–4. PMID 8569363. 

Bilberry extract, or Vaccinium myrtillus, is an anthocyanoside bioflavonoid. Supplementation with this potent flavonoid protects and maintains venous strength and function.Murray MT. (1996). Encyclopedia of Nutritional Supplements. NY: Three Rivers Press, 326. 

Surgical /non medicinal treatments

Some people require the following medical treatments for chronic or severe hemorrhoids:

• Rubber band ligation
  Sometimes called Baron ligation. Elastic bands are applied onto an internal hemorrhoid to cut off its blood supply.Longman RJ, Thomson WH (2006). "A prospective study of outcome from rubber band ligation of piles". Colorectal Dis 8 (2): 145–8. doi:10.1111/j.1463-1318.2005.00873.x. PMID 16412076.  Within several days, the withered hemorrhoid is sloughed off during normal bowel movement.
• Hemorrhoidolysis/Galvanic Electrotherapy
  Desiccation of the hemorrhoid by electrical current.
• Sclerotherapy (injection therapy)
  Sclerosant or hardening agent is injected into hemorrhoids. This causes the vein walls to collapse and the hemorrhoids to shrivel up.
• Cryosurgery
  A frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues.MacLeod JH (1982). "In defense of cryotherapy for hemorrhoids. A modified method". Dis. Colon Rectum 25 (4): 332–5. PMID 6979469.  Rarely used anymore because of side effects.
• Laser, infrared or BICAP coagulation
  laser, Infrared beam, or electricity is used to cauterize the affected tissues. Lasers are now much less popular. Infrared coagulation has been studied in comparison with RBL and found to be as effective in hemorrhoids up to grade III. These are the most readily available non-surgical procedures in the US.
• Hemorrhoidectomy
  A true surgical procedure to excise and remove hemorrhoids. Has possible correlation with incontinence issues later in life; in addition, many patients complain that pain during recovery is severe. For this reason is often now recommended only for severe (grade IV) hemorrhoids.
• Stapled Hemorrhoidectomy
  Also called the procedure for prolapse and hemorrhoids, it is designed to resect soft tissue proximal to the dentate line, which disrupts the blood flow to the hemorrhoids. It is generally less painful than complete removal of hemorrhoids and also allows for faster recovery times. It\'s meant for hemorrhoids that fall out or bleed and is not helpful for painful outside conditions.
• Enema
  This Practice is used to clean the rectum. While it is a simple procedure, it can be complicated by hemorrhoids, so in such cases, it should be done by a doctor. In an enema, water is injected into the rectum and then flushed out, cleaning the area.
• Doppler Guided Hemorrhoidal Artery Ligation
  The only evidence-based surgery for all grades of hemorrhoids. It does not involve cutting tissues or even a stay at the hospital; patients are usually back to work on the same day. It is the best treatment for bleeding piles, as the bleeding stops immediately. Scheyer M, Antonietti E, Rollinger G, Mall H, Arnold S (2006). "Doppler-guided hemorrhoidal artery ligation". Am. J. Surg. 191 (1): 89–93. doi:10.1016/j.amjsurg.2005.10.007. PMID 16399113. 
• HAL-RAR
  To date, Doppler Guided Hemorrhoidal Artery Ligation was indicated in management of Grade II & Grade III Hemorrhoids but with the availabilty of HAL Recto Anal Repair Management of prolapsing hemorrhoids without excision is also possible.
• Transanal hemorrhoidal dearterialization (THD)
  Similar to HAL, but more standardizable and therefore safer, less painful and has a shorter recovery time.

Diseases with similar symptoms

Symptoms associated with rectal cancer, anal fissure, anal abscess, anal fistula, Perianal hematoma, and other diseases may be similar to those produced by hemorrhoids and may be reduced by the topical analgesic methods described above. For this reason, it is a good idea to consult with a physician when these symptoms are encountered, particularly for the first time, and periodically should the problem continue. In the US, colonoscopy is recommended as a general diagnostic for those over age 50 (40 with family history of bowel cancers); a clear (normal) scope is good for 10 years.

References

See also

• Anal fissure
• Anal fistula
• Perianal hematoma
• Proctoscopy

External links

• Hemorrhoid at the Open Directory Project
• Hemorrhoids information
• Hemorrhoids Information
• Hemorrhoids(Fistula in Ano)

v • d • e Circulatory system pathology (I, 390-459)
Hypertension	Hypertensive heart disease - Hypertensive nephropathy - Secondary hypertension (Renovascular hypertension)
Ischaemic heart disease	Angina pectoris (Prinzmetal\'s angina) - Myocardial infarction (heart attack) - Dressler\'s syndrome
Pulmonary circulation	Pulmonary embolism - Cor pulmonale
Pericardium	Pericarditis - Pericardial effusion - Cardiac tamponade
Endocardium/heart valves	Endocarditis - mitral valves (regurgitation, prolapse, stenosis) - aortic valves (stenosis, insufficiency) - pulmonary valves (stenosis, insufficiency) - tricuspid valves (stenosis, insufficiency)
Myocardium	Myocarditis - Cardiomyopathy (Dilated cardiomyopathy, Hypertrophic cardiomyopathy, Loeffler endocarditis, Restrictive cardiomyopathy) - Arrhythmogenic right ventricular dysplasia
Electrical conduction system of the heart	Heart block: AV block (First degree, Second degree, Third degree) - Bundle branch block (Left, Right) - Bifascicular block - Trifascicular block Pre-excitation syndrome (Wolff-Parkinson-White, Lown-Ganong-Levine) - Long QT syndrome - Adams-Stokes syndrome - Cardiac arrest - Sudden cardiac death Arrhythmia: Paroxysmal tachycardia (Supraventricular, AV nodal reentrant, Ventricular) - Atrial flutter - Atrial fibrillation (Familial) - Ventricular fibrillation - Premature contraction (Atrial, Ventricular) - Ectopic pacemaker - Sick sinus syndrome
Other heart conditions	Heart failure - Cardiovascular disease - Cardiomegaly - Ventricular hypertrophy (Left, Right)
Cerebrovascular diseases	Intracranial hemorrhage/cerebral hemorrhage: Extra-axial hemorrhage (Epidural hemorrhage, Subdural hemorrhage, Subarachnoid hemorrhage) Intra-axial hematoma (Intraventricular hemorrhages, Intraparenchymal hemorrhage) - Anterior spinal artery syndrome - Binswanger\'s disease - Moyamoya disease
Arteries, arterioles and capillaries	Atherosclerosis (Renal artery stenosis) - Aortic dissection/Aortic aneurysm (Abdominal aortic aneurysm) - Aneurysm - Raynaud\'s phenomenon/Raynaud\'s disease - Buerger\'s disease - Vasculitis/Arteritis (Aortitis) - Intermittent claudication - Arteriovenous fistula - Hereditary hemorrhagic telangiectasia - Spider angioma - Dissection (Carotid artery, Vertebral artery)
Veins, lymphatic vessels and lymph nodes	Thrombosis/Phlebitis/Thrombophlebitis (Deep vein thrombosis, May-Thurner syndrome, Portal vein thrombosis, Venous thrombosis, Budd-Chiari syndrome, Renal vein thrombosis, Paget-Schroetter disease) - Varicose veins / Portacaval anastomosis (Hemorrhoid, Esophageal varices, Varicocele, Gastric varices, Caput medusae) - Superior vena cava syndrome - Lymph (Lymphadenitis, Lymphedema, Lymphangitis)
Other	Hypotension (Orthostatic hypotension)
See also congenital (Q20-Q28, 745-747)

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