Hemorrhoids

Hemorrhoids (lat.noduli haemorrhoidales) are spongy cushions in the anal canal, filled with blood. They have a role of finely closing the anal canal, and alongside the inner sphincter, they help control defecation.
They are covered with mucous tissue that includes smooth tissue which enables us the differentiation between formed stool, liquid stool and gasses. They become pathological when they get swollen, become inflamed or thrombosed, which is called hemorrhoidal disease.

Causes – Risk factor

Hemorrhoidal disease is a modern age disease. Alongside genetic heredity, bad habits play an important role: bowel disorder (diarrhea/constipation), obesity, lack of physical activity, prolonged sitting, irregular and inadequate nutrition (spicy, fat, dry, without residue). Those are also states with elevated pelvic pressure and pressure in the abdomen; pregnancy and birth, chronic cough.

Pathophysiology

Hemorrhoidal cushions are not swollen veins – the cushions are made of connective and sinusoid vessels – a shunt between arteries and veins.

Mechanism of the formation of the disease is connected with insufficiency (weakened function) of the valve mechanism inside the arterial-venous shunt. Blood transported via arteries cannot be furtherly transported by the venous part of the shunt into venous bloodstream, which leads to the enlargement of the node. With time, elastic supportive and muscle tissue of the enlarged hemorrhoidal node weakens, and it gradually descends towards the external opening of the anus. Physiological function of hemorrhoids weakens and typical symptoms of the disease occur.

Symptoms

itching, excessive moisture and perianal dermatitis
pressure and stinging in the anus
bleeding – fresh blood in the stool, on the toilet paper
pain and swelling – due to inflammation and thrombosis
prolapse of the nodes through anus

Treatment

The only therapy that effectively treats enlarged hemorrhoids is surgical (surgery).

It is common in the first stage of the disease to start the treatment with conservative therapy. It consists of hygienic-dietary measures, regulation of stool and use of symptomatic medications (creams, suppositories, compresses, baths, teas).

It is important to emphasize that conservative treatment alleviates problems only for a short period of time, but does not solve the problem permanently.

Moreover, healing and postponing of the definitive steps can only worsen the basic disease!

Choice of surgical method depends on the stage of the disease and surgeon’s expertise.

Disease classification

Grade I – mildly enlarged hemorrhoidal node accompanied by some of the symptoms

Hemorrhoids are insignificantly enlarged; detection exclusively using an anoscope.

Accompanied by light, fresh blood in the stool; mostly painless, with itching and feeling of a foreign body in the anus.

Treatment: conservative.

Grade II – significantly enlarged hemorrhoidal node, no prolapse through anus

There is a sense of pressure and fullness in the final part of the large intestine, pain during defecation, if the hemorrhoid is wedged in the anal canal. Itching and stinging are often, as well as excessive moisture.

Grade III – enlarged hemorrhoidal node with prolapse, but can be repositioned

Hemorrhoids after defecation return into the anal canal spontaneously, but they can be pressed and return using fingers – reposition. Anal mucous tissue is in this phase is firm and hard, so bleeding is rare. Pain, itching and moisturizing and present, which induces eczema of surrounding skin.

Grade IV – prolapse of hemorrhoids through the anus, without the possibility of repositioning

State of fixed anal prolapse.

Hemorrhoids are visible from the outside, they thrombose often, become inflamed, intensively sting, itch and hurt;
They cannot be returned into the anal canal. Mucous tissue is permanently prolapsed, moisturizes excessively, which leads to skin irritation, eczema and infection.
Bleeding is rare, but leads to disorders in defecation.
Long-term tissue irritation can lead to malignant disease.

Differential diagnosis

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

Other conditions that produce an anal mass include: skin tags, anal warts, rectal prolapse, polyps, and enlarged anal papillae. Anorectal varices due to increased portal hypertension (blood pressure in the portal venous system) may present similar to hemorrhoids but are a different condition.

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. Spending less time attempting to defecate, avoiding reading while on the toilet, and losing weight for overweight persons and avoiding heavy lifting are also recommended.

Misconceptions

There are several misconceptions regarding this disease:

They are not a circular formation; there are only three hemorrhoidal cushions, which are placed in specific positions; one on the left of the anus and two on the right, in front and in the back of the canal.
They do not represent enlarged vessels; cushions consist of connecting tissue and blood vessels called sinusoid vessels – arteriovenous fistulae (caving, shunts) filled with bright arterial blood, with walls made of connecting tissue, without the muscle layer.
There are no ‘internal’ and ‘external’ hemorrhoids: what people call ‘external’ hemorrhoids is actually perianal thrombosis, with no anatomic or pathophysiologic connection to hemorrhoids.