Contents
Introduction:
Symptomatic enlargement and distal displacement of the normal anal cushions.

Pathophysiology
Hemorrhoids are highly vascular submucosal cushions that generally lie along the anal canal in three columns—the left lateral, right anterior, and right posterior positions.
These vascular cushions are made up of elastic connective tissue and smooth muscle, but because some do not contain muscular walls, these cushions may be considered sinusoids instead of arteries or veins.
- Physiologic role:
- Protecting the anal sphincter muscles
- Augment closure of the anal canal during moments of increased abdominal pressure (e.g., coughing, sneezing) to prevent incontinence (contribute 15-20% of the resting anal canal pressure). Increases in abdominal pressure increase the pressure in the inferior vena cava that cause these vascular cushions to engorge and prevent leakage.
- Help differentiate stool, liquid, and gas in the anal canal.

Alteration of venous drainage of the anus
+
Destructive changes in supporting connective tissue within the anal cushion
↓
Dilation of venous plexus and connecting tissue
↓
Outgrowth of anal mucosa from the rectal wall
Classification
- Internal haemorrhoids
- External haemorrhoids
Internal haemorrhoids:
- Above the dentate line
- Drain via the middle rectal veins into the internal iliac vessels
- Covered by mucosa comprised of columnar epithelium
- Visceral innervation (painless)
External haemorrhoids:
- Below the dentate line
- Drain via the inferior rectal veins into the pudendal vessels and then into the internal iliac vein
- Covered by anoderm comprised of modified squamous epithelium.
- Somatic innervation (inferior rectal branch of pudendal nerve) (painful if thrombosed)
Goligher classification:
- Grade I: Bleed but do not prolapse
- Grade II: Prolapse but spontaneously reduce
- Grade III: Prolapse but have to be manually reduced
- Grade IV: Prolapse but cannot be reduced
- Also includes:
- Acutely thrombosed
- Incarcerated internal haemorrhoids
- Incarcerated, thrombosed haemorrhoids involving circumferential rectal mucosal prolapse
- Also includes:


Clinical features
- Painless rectal bleeding associated with bowel movement. (M/C symptom)
- Prolapsing haemorrhoids: Perineal irritation or anal itching (due to mucous secretion or faecal soiling)
- Large haemorrhoids: Feeling of incomplete evacuation or rectal fullness
- Pain: Anal fissure and perianal abscess (common causes of anal pain in hemorrhoidal patients)
- Pain is not usually caused by the hemorrhoids themselves unless:
- Thrombosed external hemorrhoid “Meleney’s 5-day lesion”
- Strangulated fourth-degree internal haemorrhoid
- Pain is not usually caused by the hemorrhoids themselves unless:
Diagnosis
Inspection:
- Perianal area for:
- Anal skin tags
- External haemorrhoid
Perianal dermatitis (from anal discharge or fecal soiling) - Fistula-in-ano and anal fissure
- Observing patients sitting and straining in squatting position: To watch for the prolapse.
Digital examination (left lateral position):
Hemorrhoid cannot be felt on DRE except when thrombosed.
- Abnormal anorectal mass
- Anal stenosis and scar
- Evaluate anal sphincter tone
- Determine the status of prostatic hypertrophy (which may be the reason for straining as this aggravates descent of the anal cushions during micturition)
Anoscopy (left lateral position):
Intrarectal retroflexion of the colonoscope or transparent anoscope with flexible endoscope also allow excellent visualization of the anal canal and haemorrhoid and permit recording pictures.
- Hemorrhoidal size, location, severity of inflammation
- Bleeding
Differential diagnosis:
Other causes of severe anal pain
- Thrombosed external haemorrhoids
- Anal fissure
- Acute herpetic ulceration or other STD
- Crohn’s ulceration & inflammation
- Anal, rectal or pelvic cancer
- Lymphoma/leukaemia
Management

Conservative management:
- High-fiber diet (25-35 g/day)
- Fiber supplementation (decreases bleeding of haemorrhoids by 50% and improves overall symptoms)
- Increased water intake
- Warm water (sitz) baths (decrease pain temporarily)
- Stool softeners
OPD procedures:
To treat grade I to III internal haemorrhoids. Have more recurrence than surgical methods but better pain management.
- Banding (better long-term success)
- Infrared photocoagulation (better pain management)
Rubber band ligation (RBL):
More effective than sclerothearpy

Surgical management:
Most effective for recurrent, highly symptomatic grade III or IV haemorrhoids. Conventional haemorrhoidectomy is more painful and associated with more blood loss and longer recovery time, but it has significantly lower rates of recurrence
- Closed hemorrhoidectomy (mucosal defect typically closed)
- Open hemorrhoidectomy (removal of hemorrhoidal tissue with mucosal defect left open)
Minimally invasive perineal hemorrhoidopexy (MIPH):
Also known as stapler hemorrhoidopexy. Purse string suture applied 2cm over dentate line.