Hemorrhoids are vascular-rich connective tissue cushions located within the anal canal. Internal hemorrhoids lie proximal to the dentate line in the anal canal; external hemorrhoids are located distal to the dentate line.
Hemorrhoidal disease presents as painless rectal bleeding or sudden onset of perianal pain with a tender palpable perianal mass.
Diagnosis is confirmed with visualization of the protruding tissue or anoscopic visualization.
Treatment for all patients includes increasing dietary fiber. Rubber band ligation is a reasonable first-line treatment choice for grade 2 and 3 internal hemorrhoids. Other treatment options for grade 2 or 3 hemorrhoids include sclerotherapy, infrared coagulation, hemorrhoid arterial ligation, or stapled hemorrhoidopexy. Surgical hemorrhoidectomy may be considered for patients with large grade 3 hemorrhoids, but it is typically reserved for patients with grade 4 hemorrhoids.
Complications include recurrence or worsening of symptoms, excessive bleeding, nonreducible prolapse, and, rarely, pelvic sepsis.
Hemorrhoidal cushions are normal anatomic structures located within the anal canal, usually occupying the left lateral and right anterior and posterior positions. As they enlarge, they can protrude outside the anal canal causing symptoms.
History and exam
Key diagnostic factors
- rectal bleeding
- intermittent protrusion
- perianal pain/discomfort
Other diagnostic factors
- anal pruritus
- tender palpable perianal lesion
- anal mass
- age between 45-65 years
- pregnancy or space-occupying pelvic lesion
- hepatic insufficiency
1st investigations to order
- anoscopic exam
- colonoscopy/flexible sigmoidoscopy
- stool for occult heme
all patients at presentation
treatment failure of rubber band ligation, sclerotherapy, infrared coagulation, transanal hemorrhoidal dearterialization, or stapled hemorrhoidopexy
- Anal fissure
- Crohn disease
- Ulcerative colitis
- ACG clinical guidelines: management of benign anorectal disorders
- The European Society of Coloproctology: guideline for haemorrhoidal disease
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