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Drugs & Diseases > Emergency Medicine

HEMORRHOIDS

Updated: May 31, 2022
* Author: Kyle R Perry, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF
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Sections
Hemorrhoids

* Sections Hemorrhoids
* Overview

* Background
* Anatomy
* Etiology and Pathophysiology
* Epidemiology
* Prognosis
* Show All
* Presentation

* History
* Physical Examination
* Grading of Internal Hemorrhoids
* Show All
* DDx
* Workup

* Approach Considerations
* Hematologic Tests
* Anoscopy and Flexible Sigmoidoscopy
* Other Diagnostic Imaging Studies
* Histologic Features
* Show All
* Treatment

* Approach Considerations
* Emergency Department Care
* Conservative Management
* Nonsurgical Procedures
* Surgical Intervention
* Long-Term Monitoring
* Show All
* Guidelines
* Medication

* Medication Summary
* Stool softeners
* Topical anesthetics
* Mild astringent
* Analgesics
* Show All
* Questions & Answers
* Media Gallery
* References

Overview

BACKGROUND

Hemorrhoids are swollen blood vessels in the lower rectum. They are among the
most common causes of anal pathology, and subsequently are blamed for virtually
any anorectal complaint by patients and medical professionals alike. Confusion
often arises because the term "hemorrhoid" has been used to refer to both normal
anatomic structures and pathologic structures. In the context of this article,
"hemorrhoids" refers to the pathologic presentation of hemorrhoidal venous
cushions.

Hemorrhoidal venous cushions are normal structures of the anorectum and are
anatomically present unless a previous intervention has taken place. Because of
their rich vascular supply, highly sensitive location, and tendency to engorge
and prolapse, hemorrhoidal venous cushions are common causes of anal pathology.
[1] Symptoms can range from mildly bothersome, such as pruritus, to quite
concerning, such as rectal bleeding.

Although hemorrhoids are a common condition diagnosed in clinical practice, many
patients are too embarrassed to seek treatment. Consequently, the true
prevalence of pathologic hemorrhoids is not known. [2] In addition, although
hemorrhoids are responsible for a large portion of anorectal complaints, it is
important to rule out more serious conditions, such as other causes of
gastrointestinal (GI) bleeding, before reflexively attributing symptoms to
hemorrhoids. [3]

In a study of 198 physicians from different specialties, Grucela et al found the
rate of correct identification for seven common, benign anal pathologic
conditions (including anal abscess, fissure, and fistula; prolapsed internal
hemorrhoid; thrombosed external hemorrhoid; condyloma acuminata; and
full-thickness rectal prolapse) was greatest for condylomata and rectal prolapse
and was lowest for hemorrhoidal conditions. [4] There was no correlation between
diagnostic accuracy and years of physician experience. The investigators found
the overall diagnostic accuracy among the physicians to be 53.5%, with the
accuracy for surgeons being 70.4% and that for the rest of the doctors being
less than 50%. [4]

HISTORICAL NOTE

Hemorrhoidal symptoms have historically been treated with dietary modifications,
incantations, voodoo, quackery, and application of a hot poker. Molten lead has
also been described as a treatment. The adverse effects of these treatments have
a direct relationship to whether patients relay persistent or recurrent
complaints to the clinician or return for further treatment.

For patient education information, see the Digestive Disorders Center as well as
Hemorrhoids, Anal Abscess, Rectal Pain, and Rectal Bleeding.

See also the following:

* Anal Surgery for Hemorrhoids

* Thrombosed External Hemorrhoid Excision

Next: Anatomy

ANATOMY

Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg,
arterioles, venules, arteriolar-venular connections), smooth muscle (eg, Treitz
muscle), and connective tissue lined by the normal epithelium of the anal canal.
Hemorrhoids are present in utero and persist through normal adult life. Evidence
indicates that hemorrhoidal bleeding is arterial and not venous. This evidence
is supported by the bright red color and arterial pH of the blood.

Hemorrhoids are classified by their anatomic origin within the anal canal and by
their position relative to the dentate line; thus, they are categorized into
internal and external hemorrhoids (see the following image).

Hemorrhoids. Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.
View Media Gallery

External hemorrhoids develop from ectoderm and are covered by squamous
epithelium, whereas internal hemorrhoids are derived from embryonic endoderm and
lined with the columnar epithelium of anal mucosa. Similarly, external
hemorrhoids are innervated by cutaneous nerves that supply the perianal area.
These nerves include the pudendal nerve and the sacral plexus. Internal
hemorrhoids are not supplied by somatic sensory nerves and therefore cannot
cause pain. At the level of the dentate line, internal hemorrhoids are anchored
to the underlying muscle by the mucosal suspensory ligament.

Hemorrhoidal venous cushions are a normal part of the human anorectum and arise
from subepithelial connective tissue within the anal canal. Internal hemorrhoids
have three main cushions, which are situated in the left lateral, right
posterior (most common), and right anterior areas of the anal canal. However,
this combination is found in only 19% of patients; hemorrhoids can be found at
any position within the rectum. Minor tufts can be found between the major
cushions.

Present in utero, these cushions surround and support distal anastomoses between
the superior rectal arteries and the superior, middle, and inferior rectal
veins. They also contain a subepithelial smooth muscle layer, contributing to
the bulk of the cushions. Normal hemorrhoidal tissue accounts for approximately
15-20% of resting anal pressure and provides important sensory information,
enabling the differentiation between solid, liquid, and gas.

External hemorrhoidal veins are found circumferentially under the anoderm; they
can cause trouble anywhere around the circumference of the anus.

Venous drainage of hemorrhoidal tissue mirrors embryologic origin. Internal
hemorrhoids drain through the superior rectal vein into the portal system.
External hemorrhoids drain through the inferior rectal vein into the inferior
vena cava. Rich anastomoses exist between these two and the middle rectal vein,
connecting the portal and systemic circulations.

Mixed hemorrhoids are confluent internal and external hemorrhoids.

Previous
Next: Anatomy

ETIOLOGY AND PATHOPHYSIOLOGY

The term hemorrhoid is usually related to the symptoms caused by hemorrhoids.
Hemorrhoids are present in healthy individuals. In fact, hemorrhoidal columns
exist in utero. When these vascular cushions produce symptoms, they are referred
to as hemorrhoids. Hemorrhoids generally cause symptoms when they become
enlarged, inflamed, thrombosed, or prolapsed.

Most symptoms arise from enlarged internal hemorrhoids. Abnormal swelling of the
anal cushions causes dilatation and engorgement of the arteriovenous plexuses.
This leads to stretching of the suspensory muscles and eventual prolapse of
rectal tissue through the anal canal. The engorged anal mucosa is easily
traumatized, leading to rectal bleeding that is typically bright red due to high
blood oxygen content within the arteriovenous anastomoses. Prolapse leads to
soiling and mucus discharge (triggering pruritus) and predisposes to
incarceration and strangulation.

Although many patients and clinicians believe that hemorrhoids are caused by
chronic constipation, prolonged sitting, and vigorous straining, little evidence
to support a causative link exists. Some of these potential etiologies are
briefly discussed below.

DECREASED VENOUS RETURN

Most authors agree that low-fiber diets cause small-caliber stools, which result
in straining during defecation. This increased pressure causes engorgement of
the hemorrhoids, possibly by interfering with venous return. Pregnancy and
abnormally high tension of the internal sphincter muscle can also cause
hemorrhoidal problems, presumably by means of the same mechanism, which is
thought to be decreased venous return. Prolonged sitting on a toilet (eg, while
reading) is believed to cause a relative venous return problem in the perianal
area (a tourniquet effect), resulting in enlarged hemorrhoids. Aging causes
weakening of the support structures, which facilitates prolapse. Weakening of
support structures can occur as early as the third decade of life.

STRAINING AND CONSTIPATION

Straining and constipation have long been thought of as culprits in the
formation of hemorrhoids. This may or may not be true. [5, 6, 7] Patients who
report hemorrhoids have a canal resting tone that is higher than normal. Of
interest, the resting tone is lower after hemorrhoidectomy than it is before the
procedure. This change in resting tone is the mechanism of action of Lord
dilatation, a surgical procedure for anorectal complaints that is most commonly
performed in the United Kingdom.

PREGNANCY

Pregnancy clearly predisposes women to symptoms from hemorrhoids, although the
etiology is unknown. Notably, most patients revert to their previously
asymptomatic state after delivery. The relationship between pregnancy and
hemorrhoids lends credence to hormonal changes or direct pressure as the
culprit.

PORTAL HYPERTENSION AND ANORECTAL VARICES

Portal hypertension has often been mentioned in conjunction with hemorrhoids.
[8, 9, 10] However, hemorrhoidal symptoms do not occur more frequently in
patients with portal hypertension than in those without it, and massive bleeding
from hemorrhoids in these patients is unusual. Bleeding is very often
complicated by coagulopathy. If bleeding is found, direct suture ligation of the
offending column is suggested.

Anorectal varices are common in patients with portal hypertension. [11] Varices
occur in the midrectum, at connections between the portal system and the middle
and inferior rectal veins. Varices occur more frequently in patients who are
noncirrhotic, and they rarely bleed. Treatment is usually directed at the
underlying portal hypertension. Emergent control of bleeding can be obtained
with suture ligation. Portosystemic shunts and transjugular intrahepatic
portosystemic shunts (TIPS) have been used to control hypertension and thus, the
bleeding. [12]

OTHER RISK FACTORS

Other risk factors historically associated with the development of hemorrhoids
include the following:

* Lack of erect posture

* Familial tendency

* Higher socioeconomic status

* Chronic diarrhea

* Colon malignancy

* Hepatic disease

* Obesity

* Elevated anal resting pressure

* Spinal cord injury

* Loss of rectal muscle tone

* Rectal surgery

* Episiotomy

* Anal intercourse

* Inflammatory bowel disease, including ulcerative colitis, and Crohn disease

PATHOPHYSIOLOGY OF SYMPTOMS OF INTERNAL HEMORRHOIDS

Internal hemorrhoids cannot cause cutaneous pain, because they are above the
dentate line and are not innervated by cutaneous nerves. However, they can
bleed, prolapse, and, as a result of the deposition of an irritant onto the
sensitive perianal skin, cause perianal itching and irritation. Internal
hemorrhoids can produce perianal pain by prolapsing and causing spasm of the
sphincter complex around the hemorrhoids. This spasm results in discomfort while
the prolapsed hemorrhoids are exposed. This muscle discomfort is relieved with
reduction.

Internal hemorrhoids can also cause acute pain when incarcerated and
strangulated. Again, the pain is related to the sphincter complex spasm.
Strangulation with necrosis may cause more deep discomfort. When these
catastrophic events occur, the sphincter spasm often causes concomitant external
thrombosis. External thrombosis causes acute cutaneous pain. This constellation
of symptoms is referred to as acute hemorrhoidal crisis and usually requires
emergent treatment.

Internal hemorrhoids most commonly cause painless bleeding with bowel movements.
The covering epithelium is damaged by the hard bowel movement, and the
underlying veins bleed. With spasm of the sphincter complex elevating pressure,
the internal hemorrhoidal veins can spurt.

Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse.
This mucus with microscopic stool contents can cause a localized dermatitis,
which is called pruritus ani. Generally, hemorrhoids are merely the vehicle by
which the offending elements reach the perianal tissue. Hemorrhoids are not the
primary offenders.

PATHOPHYSIOLOGY OF SYMPTOMS OF EXTERNAL HEMORRHOIDS

External hemorrhoids cause symptoms in two ways. First, acute thrombosis of the
underlying external hemorrhoidal vein can occur. Acute thrombosis is usually
related to a specific event, such as physical exertion, straining with
constipation, a bout of diarrhea, or a change in diet. These are acute, painful
events.

Pain results from rapid distention of innervated skin by the clot and
surrounding edema. The pain lasts 7-14 days and resolves with resolution of the
thrombosis. With this resolution, the stretched anoderm persists as excess skin
or skin tags. External thromboses occasionally erode the overlying skin and
cause bleeding. Recurrence occurs approximately 40-50% of the time, at the same
site (because the underlying damaged vein remains there). Simply removing the
blood clot and leaving the weakened vein in place, rather than excising the
offending vein with the clot, will predispose the patient to recurrence.

External hemorrhoids can also cause hygiene difficulties, with the excess,
redundant skin left after an acute thrombosis (skin tags) being accountable for
these problems. External hemorrhoidal veins found under the perianal skin
obviously cannot cause hygiene problems; however, excess skin in the perianal
area can mechanically interfere with cleansing.

Previous
Next: Anatomy

EPIDEMIOLOGY

Worldwide, the prevalence of symptomatic hemorrhoids is estimated at 4.4% in the
general population. In the United States, up to one third of the 10 million
people with hemorrhoids seek medical treatment, resulting in 1.5 million related
prescriptions per year.

The number of hemorrhoidectomies performed in US hospitals is declining. A peak
of 117 hemorrhoidectomies per 100,000 people was reached in 1974; this rate
declined to 37 hemorrhoidectomies per 100,000 people in 1987. Outpatient and
office treatment of hemorrhoids account for some of this decline.

Patients presenting with hemorrhoidal disease are more frequently white, from
higher socioeconomic status, and from rural areas. There is no known sex
predilection, although men are more likely to seek treatment. However, pregnancy
causes physiologic changes that predispose women to developing symptomatic
hemorrhoids. As the gravid uterus expands, it compresses the inferior vena cava,
causing decreased venous return and distal engorgement.

External hemorrhoids occur more commonly in young and middle-aged adults than in
older adults. The prevalence of hemorrhoids increases with age, with a peak in
persons aged 45-65 years.

Previous
Next: Anatomy

PROGNOSIS

Most hemorrhoids resolve spontaneously or with conservative medical therapy
alone. However, complications can include thrombosis, secondary infection,
ulceration, abscess, and incontinence. The recurrence rate with nonsurgical
techniques is 10-50% over a 5-year period, whereas that of surgical
hemorrhoidectomy is less than 5%.

Regarding complications from surgery, well-trained surgeons should experience
complications in fewer than 5% of cases. Complications include stenosis,
bleeding, infection, recurrence, nonhealing wounds, and fistula formation.
Urinary retention is directly related to the anesthetic technique used and to
the perioperative fluids administered. Limiting fluids and the routine use of
local anesthesia can reduce urinary retention to less than 5%.

Clinical Presentation

REFERENCES

1. Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine:
Concepts and Clinical Practice. 6th ed. Philadelphia, Pa: Elsevier; 2006.
1509-12.

2. Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A
Comprehensive Study Guide. 6th ed. New York, NY: McGraw Hill; 2004. 540-1.

3. Ibrahim AM, Hackford AW, Lee YM, Cave DR. Hemorrhoids can be a source of
obscure gastrointestinal bleeding that requires transfusion: report of five
patients. Dis Colon Rectum. 2008 Aug. 51(8):1292-4. [QxMD MEDLINE Link].

4. Grucela A, Salinas H, Khaitov S, Steinhagen RM, Gorfine SR, Chessin DB.
Prospective analysis of clinician accuracy in the diagnosis of benign anal
pathology: comparison across specialties and years of experience. Dis Colon
Rectum. 2010 Jan. 53(1):47-52. [QxMD MEDLINE Link].

5. Gibbons CP, Bannister JJ, Read NW. Role of constipation and anal hypertonia
in the pathogenesis of haemorrhoids. Br J Surg. 1988 Jul. 75(7):656-60.
[QxMD MEDLINE Link].

6. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic
constipation. An epidemiologic study. Gastroenterology. 1990 Feb.
98(2):380-6. [QxMD MEDLINE Link].

7. Johanson JF, Sonnenberg A. Constipation is not a risk factor for
hemorrhoids: a case-control study of potential etiological agents. Am J
Gastroenterol. 1994 Nov. 89(11):1981-6. [QxMD MEDLINE Link].

8. Bernstein WC. What are hemorrhoids and what is their relationship to the
portal venous system?. Dis Colon Rectum. 1983 Dec. 26(12):829-34. [QxMD
MEDLINE Link].

9. Hosking SW, Smart HL, Johnson AG, Triger DR. Anorectal varices,
haemorrhoids, and portal hypertension. Lancet. 1989 Feb 18. 1(8634):349-52.
[QxMD MEDLINE Link].

10. Johansen K, Bardin J, Orloff MJ. Massive bleeding from hemorrhoidal varices
in portal hypertension. JAMA. 1980 Nov 7. 244(18):2084-5. [QxMD MEDLINE
Link].

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Media Gallery

* Hemorrhoids. Anatomy of external hemorrhoid. Image courtesy of MedicineNet,
Inc.

* Hemorrhoids. Thrombosed hemorrhoid. This hemorrhoid was treated by incision
and removal of a clot.

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CONTRIBUTOR INFORMATION AND DISCLOSURES

Author

Kyle R Perry, MD Emergency Physician, The Queen's Medical Center; Volunteer
Faculty, University of Hawaii, John A Burns School of Medicine