Hemorrhoids

Swollen of normal blood vessels at lower rectum (hemorrhoidal venous cushions)

Hemorrhoidal venous cushions are a normal part of the human anorectum and arise from subepithelial connective tissue within the anal canal.

Normal hemorrhoidal tissue:

  • 15-20% of resting anal pressure
  • Provides important sensory information, enabling the differentiation between solid, liquid, and gas
  • Help in defecation

Classified by their anatomic origin within the anal canal and by their position relative to the dentate line into internal and external

External hemorrhoids:

  • Develop from ectoderm and are covered by squamous epithelium.

  • Innervated by cutaneous nerves that supply the perianal area. These nerves include the pudendal nerve and the sacral plexus.

  • External hemorrhoids drain through the inferior rectal vein into the inferior vena cava.

  • External hemorrhoidal veins are found circumferentially under the anoderm

Internal hemorrhoids:

  • Derived from endoderm and lined with columnar epithelium of anal mucosa.

  • No somatic sensory nerves

  • Internal hemorrhoids drain through the superior rectal vein into the portal system.

  • Rich anastomoses exist between these 2 and the middle rectal vein, connecting the portal and systemic circulations.

Internal hemorrhoids have 3 main cushions:

  • Left lateral
  • Right posterior (most common)
  • Right anterior areas
  • Minor tufts can be found between the major cushions.

Etiology:

  • Degeneration of the supporting fibroelastic tissue and smooth muscle
  • Decreased venous return
  • Portal hypertension and anorectal varices
  • Increased intra-abdominal pressure:
    • Straining and constipation
    • Pregnancy (Combined !!)
    • Weight lifting

Symptoms:

  • Depends on the type
  • Fresh PR bleeding
  • Anal pain with swelling

Complications:

  • Thrombosis
  • Prolapse
  • Erosions

Grades of internal types:

  • Grade I: Project into the anal canal and often bleed
  • Grade II: Protrude beyond anal verge with straining but reduced spontaneously
  • Grade III: Protrude spontaneously and require manual reduction
  • Grade IV: chronically prolapse and cannot be reduced

Diagnosis:

  • Clinically, DRE, Anoscope

Management:

  • Type, symptoms, and grades
  • Local vs systemic
  • Conservative therapy
  • Surgical therapy:
    • Indications
    • External haemorrhoides: Incision, & clot evacuation
    • Internal haemorrhoides: Banding, Conventional, Stappled, ligasure