Hemorrhoid

Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal.<ref>Template:Cite book</ref><ref name=World09>Template:Cite journal</ref> In their normal state, they are cushions that help with stool control.<ref name=Beck2011>Template:Cite book</ref> They become a disease when swollen or inflamed; the unqualified term hemorrhoid is often used to refer to the disease.<ref name=World09 /> The signs and symptoms of hemorrhoids depend on the type present.<ref name=Sun2016 /> Internal hemorrhoids often result in painless, bright red rectal bleeding when defecating.<ref name=NIH2013>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref name=Sun2016 /> External hemorrhoids often result in pain and swelling in the area of the anus.<ref name=Sun2016 /> If bleeding occurs, it is usually darker.<ref name=Sun2016 /> Symptoms frequently get better after a few days.<ref name=NIH2013 /> A skin tag may remain after the healing of an external hemorrhoid.<ref name=Sun2016 />

While the exact cause of hemorrhoids remains unknown, a number of factors that increase pressure in the abdomen are believed to be involved.<ref name=Sun2016 /> This may include constipation, diarrhea, and sitting on the toilet for long periods.<ref name=NIH2013 /> Hemorrhoids are also more common during pregnancy.<ref name=NIH2013 /> Diagnosis is made by looking at the area.<ref name=NIH2013 /> Many people incorrectly refer to any symptom occurring around the anal area as hemorrhoids, and serious causes of the symptoms should not be ruled out.<ref name=Beck2011 /> Colonoscopy or sigmoidoscopy is reasonable to confirm the diagnosis and rule out more serious causes.<ref name=PG2016>Template:Cite journal</ref>

Often, no specific treatment is needed.<ref name=PG2016 /> Initial measures consist of increasing fiber intake, drinking fluids to maintain hydration, NSAIDs to help with pain, and rest.<ref name=Review09 /> Medicated creams may be applied to the area, but their effectiveness is poorly supported by evidence.<ref name=PG2016 /> A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management.<ref name=NG2011 /> Hemorrhoidal artery embolization (HAE) is a safe and effective minimally invasive procedure that can be performed and is typically better tolerated than traditional therapies.<ref name=":0" /><ref name=":1" /><ref name=":3" /> Surgery is reserved for those who fail to improve following these measures.<ref name=NG2011>Template:Cite journal</ref>

Approximately 50% to 66% of people have problems with hemorrhoids at some point in their lives.<ref name=Review09 /><ref name=NIH2013 /> Males and females are both affected with about equal frequency.<ref name=Review09>Template:Cite journal</ref> Hemorrhoids affect people most often between 45 and 65 years of age,<ref name=Kaidar2007>Template:Cite journal</ref> and they are more common among the wealthy,<ref name=Sun2016>Template:Cite journal</ref> although this may reflect differences in healthcare access rather than true prevalence.<ref name="p663" /> Outcomes are usually good.<ref name=NIH2013 /><ref name=PG2016 />

The first known mention of the disease is from a 1700 BC Egyptian papyrus.<ref name="Charles2002(book)">Template:Cite book</ref> Template:TOC limit

Signs and symptoms

File:M 44 anus 22.jpg

An external hemorrhoid

In about 40% of people with pathological hemorrhoids, there are no significant symptoms.<ref name=Sun2016 /> Internal and external hemorrhoids may present differently; however, many people may have a combination of the two.<ref name=World09 /> Bleeding enough to cause anemia is rare,<ref name=Kaidar2007 /> and life-threatening bleeding is even more uncommon.<ref name=AFP2006 /> Many people feel embarrassed when facing the problem<ref name=Kaidar2007 /> and often seek medical care only when the case is advanced.<ref name=World09 />

External

If not thrombosed, external hemorrhoids may cause few problems.<ref name=Day2006 /> However, when thrombosed, hemorrhoids may be very painful.<ref name=Review09 /><ref name=World09 /> Nevertheless, this pain typically resolves in two to three days.<ref name=Kaidar2007 /> The swelling may, however, take a few weeks to disappear.<ref name=Kaidar2007 /> A skin tag may remain after healing.<ref name=World09 /> If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus.<ref name=Day2006 />

Internal

Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement.<ref name=World09 /> The blood typically covers the stool (a condition known as hematochezia), is on the toilet paper, or drips into the toilet bowl.<ref name=World09 /> The stool itself is usually normally coloured.<ref name=World09 /> Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus, itchiness, and fecal incontinence.<ref name=AFP2006>Template:Cite journal</ref><ref>Template:Cite book</ref> Internal hemorrhoids are usually painful only if they become thrombosed or necrotic.<ref name=World09 />

Causes

The exact cause of symptomatic hemorrhoids is unknown.<ref name=CE2009 /> A number of factors are believed to play a role, including irregular bowel habits (constipation or diarrhea), lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining, ascites, an intra-abdominal mass, or pregnancy), genetics, an absence of valves within the hemorrhoidal veins, and aging.<ref name=Review09 /><ref name=Kaidar2007 /> Other factors believed to increase risk include obesity, prolonged sitting,<ref name=World09 />{{ safesubst:#invoke:Unsubst||date=__DATE__ |$B= Template:Fix }} a chronic cough, and pelvic floor dysfunction.<ref name=Beck2011 /> Squatting while defecating may also increase the risk of severe hemorrhoids.<ref>Template:Cite book</ref> Evidence for these associations, however, is poor.<ref name=Beck2011 /> Being a receptive partner in anal intercourse has been listed as a cause.<ref>Template:Cite book</ref><ref>Template:Cite book</ref><ref>Template:Cite book</ref>

During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery.<ref name=Review09 />

Pathophysiology

File:Gross pathology of hemorrhoids.jpg

Gross pathology of hemorrhoids, showing engorged blood vessels

Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes.<ref name=World09 /> There are three main cushions present in the normal anal canal.<ref name=Review09 /> These are located classically at left lateral, right anterior, and right posterior positions.<ref name=Kaidar2007 /> They are composed of neither arteries nor veins, but blood vessels called sinusoids, connective tissue, and smooth muscle.<ref name=Beck2011 />Template:Rp Sinusoids do not have muscle tissue in their walls, as veins do.<ref name=World09 /> This set of blood vessels is known as the hemorrhoidal plexus.<ref name=Beck2011 />

Hemorrhoid cushions are important for continence. They contribute to 15–20% of anal closure pressure at rest and protect the internal and external anal sphincter muscles during the passage of stool.<ref name=World09 /> When a person bears down, the intra-abdominal pressure grows, and hemorrhoid cushions increase in size, helping maintain anal closure.<ref name=Kaidar2007 /> Hemorrhoid symptoms are believed to result when these vascular structures slide downwards or when venous pressure is excessively increased.<ref name=AFP2006 /> Increased internal and external anal sphincter pressure may also be involved in hemorrhoid symptoms.<ref name=Kaidar2007 /> Two types of hemorrhoids occur: internals from the superior hemorrhoidal plexus and externals from the inferior hemorrhoidal plexus.<ref name=Kaidar2007 /> The pectinate line divides the two regions.<ref name=Kaidar2007 />

Diagnosis

Internal hemorrhoid grades

Grade	Diagram	Picture
1	File:Piles Grade 1.svg	Endoscopic view
2	File:Piles Grade 2.svg	File:Hemrrhoids 04.jpg
3	File:Piles Grade 3.svg	File:Hemrrhoids 05.jpg
4	File:Piles Grade 4.svg	File:Piles 4th deg 01.jpg

Hemorrhoids are typically diagnosed by physical examination.<ref name=NG2011 /> A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids.<ref name=World09 /> Visual confirmation of internal hemorrhoids, on the other hand, may require anoscopy, insertion of a hollow tube device with a light attached at one end.<ref name="Kaidar2007" /> A digital rectal exam (DRE) can also be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses.<ref name=World09 /> This examination may not be possible without appropriate sedation because of pain, although most internal hemorrhoids are not associated with pain.<ref name=Review09 /> If pain is present, the condition is more likely to be an anal fissure or external hemorrhoid rather than internal hemorrhoid.<ref name=Kaidar2007 />

Internal

Internal hemorrhoids originate above the pectinate line.<ref name=Day2006 /> They are covered by columnar epithelium, which lacks pain receptors.<ref name=Beck2011 /> They were classified in 1985 into four grades based on the degree of prolapse:<ref name=Review09 /><ref name=Beck2011 />

• Grade I: No prolapse, just prominent blood vessels<ref name=NG2011 />
• Grade II: Prolapse upon bearing down, but spontaneous reduction
• Grade III: Prolapse upon bearing down requiring manual reduction
• Grade IV: Prolapse with inability to be manually reduced.

External

File:Perianal thrombosis 01.jpg

A thrombosed external hemorrhoid

External hemorrhoids occur below the dentate (or pectinate) line.<ref name=Day2006 /> They are covered proximally by anoderm and distally by skin, both of which are sensitive to pain and temperature.<ref name=Beck2011 />

Differential

Many anorectal problems, including fissures, fistulae, abscesses, colorectal cancer, rectal varices, and itching have similar symptoms and may be incorrectly referred to as hemorrhoids.<ref name=Review09 /> Rectal bleeding may also occur owing to colorectal cancer, colitis including inflammatory bowel disease, diverticular disease, and angiodysplasia.<ref name=NG2011 /> If anemia is present, other potential causes should be considered.<ref name=Kaidar2007 />

Other conditions that produce an anal mass include skin tags, anal warts, rectal prolapse, polyps, and enlarged anal papillae.<ref name=Kaidar2007 /> Anorectal varices due to portal hypertension (blood pressure in the portal venous system) may present similar to hemorrhoids but are a different condition.<ref name=Kaidar2007 /> Portal hypertension does not increase the risk of hemorrhoids.<ref name=Sun2016 />

Prevention

A number of preventative measures are recommended, including avoiding straining while attempting to defecate, avoiding constipation and diarrhea either by eating a high-fiber diet and drinking plenty of fluid or by taking fiber supplements and getting sufficient exercise.<ref name=Kaidar2007 /><ref>Template:Cite book</ref> Spending less time attempting to defecate, avoiding reading while on the toilet,<ref name=Review09 /> and losing weight for overweight persons and avoiding heavy lifting are also recommended.<ref>Template:Cite book</ref>

Management

Conservative

Conservative treatment typically consists of foods rich in dietary fiber, intake of oral fluids to maintain hydration, nonsteroidal anti-inflammatory drugs, sitz baths, and rest.<ref name=Review09 /> Increased fiber intake has been shown to improve outcomes<ref name=Alon2005>Template:Cite journal</ref> and may be achieved by dietary alterations or the consumption of fiber supplements.<ref name=Review09 /><ref name=Alon2005 /> Evidence for benefits from sitz baths during any point in treatment, however, is lacking.<ref>Template:Cite journal</ref> If they are used, they should be limited to 15 minutes at a time.<ref name=Beck2011 />Template:Rp Decreasing time spent on the toilet and not straining is also recommended.<ref name=Dav2018>Template:Cite journal</ref>

While many topical agents and suppositories are available for the treatment of hemorrhoids, little evidence supports their use.<ref name=Review09 /> As such, they are not recommended by the American Society of Colon and Rectal Surgeons.<ref name="ASCRS2018" /> Steroid-containing agents should not be used for more than 14 days, as they may cause thinning of the skin.<ref name=Review09 /> Most agents include a combination of active ingredients.<ref name=Beck2011 /> These may include a barrier cream such as petroleum jelly or zinc oxide, an analgesic agent such as lidocaine, and a vasoconstrictor such as epinephrine.<ref name=Beck2011 /> Some contain Balsam of Peru to which certain people may be allergic.<ref name="dermnetnz1">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref><ref>Template:Cite book</ref>

Flavonoids are of questionable benefit, with potential side effects.<ref name=Beck2011 /><ref>Template:Cite journal</ref> Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery.<ref>Template:Cite journal</ref> Evidence does not support the use of traditional Chinese herbal treatment.<ref>Template:Cite journal</ref>

The use of phlebotonics has been investigated in the treatment of low-grade hemorrhoids,<ref name="ASCRS2018">Template:Cite journal</ref><ref name="Perera2012">Template:Cite journal</ref><ref>Template:Cite journal</ref><ref>Template:Cite journal</ref> although these drugs are not approved for such use in the United States or Germany.<ref>Template:Cite book</ref><ref name="Stucker2016">Template:Cite journal</ref> The use of phlebotonics for the treatment of chronic venous diseases is restricted in Spain.<ref>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref>

Procedures

A number of office-based procedures may be performed. While generally safe, rare serious side effects such as perianal sepsis may occur.<ref name=NG2011 />

1. Rubber band ligation is typically recommended as the first-line treatment in those with grade I to III disease.<ref name="NG2011" /> It is a procedure in which elastic bands are applied onto internal hemorrhoid at least 1 cm above the pectinate line to cut off its blood supply. Within 5–7 days, the withered hemorrhoid falls off. If the band is placed too close to the pectinate line, intense pain results immediately afterwards.<ref name="Review09" /> The cure rate has been found to be about 87%,<ref name="Review09" /> with a complication rate of up to 3%.<ref name="NG2011" />
2. Sclerotherapy involves the injection of a sclerosing agent, such as phenol, into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate four years after treatment is about 70%.<ref name="Review09" />
3. A number of cauterization methods have been shown to be effective for hemorrhoids, but are usually used only when other methods fail. This procedure can be done using electrocautery, infrared radiation, laser surgery,<ref name="Review09" /> or cryosurgery.<ref>Template:Cite journal</ref> Infrared cauterization may be an option for grade I or II disease.<ref name="NG2011" /> In those with grade III or IV disease, reoccurrence rates are high.<ref name="NG2011" />

Hemorrhoidal artery embolization (HAE) is an additional minimally invasive procedure performed by an interventional radiologist.<ref name=":0">{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> HAE involves the blockage of abnormal blood flow to the rectal (hemorrhoidal) arteries using microcoils and/or microparticles to decrease the size of the hemorrhoids and improve hemorrhoid related symptoms, especially bleeding.<ref name=":1">Template:Cite AV media</ref> HAE is very effective at stopping bleeding related symptom with success rate of approximately 90%.<ref name=":3">Template:Cite journal</ref>

Surgery

A number of surgical techniques may be used if conservative management and simple procedures fail.<ref name=NG2011 /> All surgical treatments are associated with some degree of complications, including bleeding, infection, anal strictures, and urinary retention, due to the close proximity of the rectum to the nerves that supply the bladder.<ref name=Review09 /> Also, a small risk of fecal incontinence occurs, particularly of liquid,<ref name=Beck2011 /><ref name="Pescatori 2008">Template:Cite journal</ref> with rates reported between 0% and 28%.<ref>Template:Cite journal</ref> Mucosal ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis).<ref name=Garcia2002>Template:Cite journal</ref> This is where the anal mucosa becomes everted from the anus, similar to a very mild form of rectal prolapse.<ref name=Garcia2002 />

1. Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily only in severe cases.<ref name="Review09" /> It is associated with significant postoperative pain and usually requires two to four weeks for recovery.<ref name="Review09" /> However, the long-term benefit is greater in those with grade III hemorrhoids as compared to rubber band ligation.<ref>Template:Cite journal</ref> It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24–72 hours.<ref name="NG2011" /><ref name="Day2006">Template:Cite book</ref> Evidence to support this is weak, however.<ref name="Dav2018" /> Glyceryl trinitrate ointment after the procedure helps both with pain and with healing.<ref>Template:Cite journal</ref>
2. Doppler-guided transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound Doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate but fewer complications compared to a hemorrhoidectomy.<ref name="Review09" />
3. Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy, involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomical position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids.<ref name="Review09" /> However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorrhoidectomy,<ref name="Jaya2006">Template:Cite journal</ref> so it is typically recommended only for grade II or III disease.<ref name="NG2011" />

Epidemiology

It is difficult to determine how common hemorrhoids are as many people with the condition do not see a healthcare provider.<ref name=AFP2006 /><ref name=CE2009>Template:Cite journal</ref> However, symptomatic hemorrhoids are thought to affect at least 50% of the US population at some time during their lives, and around 5% of the population is affected at any given time.<ref name=Review09 /> Both sexes experience about the same incidence of the condition,<ref name=Review09 /> with rates peaking between 45 and 65 years.<ref name=Kaidar2007 /> Some studies have found that they are common in people of higher socioeconomic status,<ref name=Beck2011 /> however this may reflect differences in healthcare access rather than true prevalence.<ref name="p663">Template:Cite journal</ref>

Long-term outcomes are generally good, though some people may have recurrent symptomatic episodes.<ref name=AFP2006 /> Only a small proportion of persons end up needing surgery.<ref name=Beck2011 />

History

File:11th century English surgery.jpg

An 11th-century English miniature. On the right is an operation to remove hemorrhoids.

The first known mention of this disease is from a 1700 BC Egyptian papyrus, which advises: "Thou shouldest give a recipe, an ointment of great protection; acacia leaves, ground, titurated and cooked together. Smear a strip of fine linen there-with and place in the anus, that he recovers immediately."<ref name="Charles2002(book)" /> In 460 BC, the Hippocratic corpus discusses a treatment similar to modern rubber band ligation: "And hemorrhoids in like manner you may treat by transfixing them with a needle and tying them with very thick and woolen thread, for application, and do not foment until they drop off, and always leave one behind; and when the patient recovers, let him be put on a course of Hellebore."<ref name="Charles2002(book)" /> Hemorrhoids may have been described in the Bible, with earlier English translations using the now-obsolete spelling "emerods".<ref name=Kaidar2007 />

Celsus (25 BC – 14 AD) described ligation and excision procedures and discussed the possible complications.<ref name="Agbo 2011" /> Galen advocated severing the connection of the arteries to veins, claiming it reduced both pain and the spread of gangrene.<ref name="Agbo 2011">Template:Cite journal</ref> The Susruta Samhita (4th–5th century BC) is similar to the words of Hippocrates, but emphasizes wound cleanliness.<ref name="Charles2002(book)" /> In the 13th century, European surgeons such as Lanfranc of Milan, Guy de Chauliac, Henri de Mondeville, and John of Ardene made great progress and development of the surgical techniques.<ref name="Agbo 2011" />

In medieval times, hemorrhoids were also known as Saint Fiacre's curse after a sixth-century saint who developed them following tilling the soil.<ref name=ascr1>{{#invoke:citation/CS1|citation |CitationClass=web }}</ref> The first use of the word hemorrhoid in English occurs in 1398, derived from the Old French {{#invoke:Lang|lang}}, from Latin {{#invoke:Lang|lang}},<ref>hæmorrhoida Template:Webarchive, Charlton T. Lewis, Charles Short, A Latin Dictionary, on Perseus Digital Library</ref> in turn from the Greek {{#invoke:Lang|lang}} ({{#invoke:Lang|lang}}), Template:Gloss, from {{#invoke:Lang|lang}} ({{#invoke:Lang|lang}}), Template:Gloss<ref>αἷμα Template:Webarchive, Henry George Liddell, Robert Scott, A Greek-English Lexicon, on Perseus Digital Library</ref> and {{#invoke:Lang|lang}} ({{#invoke:Lang|lang}}), Template:Gloss,<ref>ῥόος Template:Webarchive, Henry George Liddell, Robert Scott, A Greek-English Lexicon, on Perseus Digital Library</ref> itself from {{#invoke:Lang|lang}} ({{#invoke:Lang|lang}}), Template:Gloss.<ref>ῥέω Template:Webarchive, Henry George Liddell, Robert Scott, A Greek-English Lexicon, on Perseus Digital Library</ref>

Notable cases

• Hall-of-Fame baseball player George Brett was removed from a game in the 1980 World Series due to hemorrhoid pain. After undergoing minor surgery, Brett returned to play in the next game, quipping, "My problems are all behind me".<ref>Template:Cite news</ref> Brett underwent further hemorrhoid surgery the following spring.<ref>Template:Cite news</ref>
• Conservative political commentator Glenn Beck underwent surgery for hemorrhoids, subsequently describing his unpleasant experience in a widely viewed 2008 YouTube video.<ref>Template:Cite news</ref><ref>{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

• Former U.S. President Jimmy Carter had surgery for hemorrhoids in 1984.<ref>Template:Cite news</ref>
• Cricketers Matthew Hayden and Viv Richards have suffered the condition.<ref>{{#invoke:citation/CS1|citation

|CitationClass=web }}</ref>

• During World War II, US Army Lieutenant Colonel Harold Cohen was selected by General George S. Patton to organize a raid to rescue Patton's son-in-law from a German prison camp; Cohen was prevented from leading the raid due to hemorrhoids.<ref name=":2">Template:Cite journal</ref> Patton personally examined Cohen and remarked, "that is some sorry ass".<ref>Template:Cite book</ref>

External links

• Template:Cite journal