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Hemorrhoids

Hemorrhoids is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • Varicosities of the hemorrhoidal venous plexus
  • External hemorrhoids
    • Located below the dentate line (painful)
    • Covered by squamous epithelium
  • Internal hemorrhoids
    • Located above the dentate line (painless)
    • Both types of hemorrhoids often coexist.
    • Classification of internal hemorrhoids:
      • 1st-degree: Hemorrhoids do not prolapse.
      • 2nd-degree: prolapse through the anus on straining but reduce spontaneously
      • 3rd-degree: protrude and require digital reduction
      • 4th-degree: cannot be reduced
  • Hemorrhoids often progress from itching and bleeding to protrusion with easy reduction, then difficult reduction, and finally, rectal prolapse. Thrombosis may occur at any stage of protrusion. External hemorrhoids cause pain; internal hemorrhoids generally do not (1).

Geriatric Considerations
Hemorrhoids are more common in elderly, as is rectal prolapse.

Pediatric Considerations
  • Uncommon in infants and children; when discovered, look for underlying cause (e.g., vena caval or mesenteric obstruction, cirrhosis, portal hypertension [HTN]).
  • Occasionally, as in adults, hemorrhoids may result from chronic constipation, fecal impaction, and straining at stool; surgery rarely required in children
Pregnancy Considerations
  • Common in pregnancy
  • Usually resolves after pregnancy
  • No treatment required, unless extremely painful

Epidemiology

  • Predominant age: adults; peak from 45 to 65 years
  • Predominant sex: male = female

Incidence
Common

Prevalence
~4–5% in general population in the United States

Etiology and Pathophysiology

  • There are three primary hemorrhoidal cushions—typically located in left lateral, right anterior, and right posterior positions. Hemorrhoidal cushions augment anal closing pressure and protect the anal sphincter during stool passage. During Valsalva, increased intra-abdominal pressure raises pressure within the hemorrhoidal cushions. Mechanisms implicated in symptomatic hemorrhoidal disease include:
    • Dilated veins of hemorrhoidal plexus
    • Tight internal anal sphincter
    • Abnormal distention of the arteriovenous anastomosis
    • Prolapse of the cushions and the surrounding connective tissues

Genetics
No known genetic pattern

Risk Factors

  • Pregnancy
  • Pelvic space-occupying lesions
  • Liver disease; portal HTN
  • Constipation
  • Occupations that require prolonged sitting
  • Loss of perianal muscle tone due to old age, rectal surgery, birth trauma/episiotomy, anal intercourse
  • Obesity
  • Chronic diarrhea

General Prevention

  • Avoid constipation by consuming high-fiber diet (>30 g/day) and ensuring proper hydration.
  • Maintain appropriate weight.
  • Avoid prolonged sitting or straining on the toilet.

Commonly Associated Conditions

  • Liver disease; portal HTN
  • Pregnancy
  • Constipation

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Citation

Stephens, Mark B., et al., editors. "Hemorrhoids." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116261/all/Hemorrhoids.
Hemorrhoids. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116261/all/Hemorrhoids. Accessed March 22, 2019.
Hemorrhoids. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116261/all/Hemorrhoids
Hemorrhoids [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 March 22]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116261/all/Hemorrhoids.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Hemorrhoids ID - 116261 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116261/all/Hemorrhoids PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -