Hemorrhoids
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Basics

Description

  • Varicosities of the hemorrhoidal venous plexus
  • External hemorrhoids:
    • Located below the dentate line
    • Covered by squamous epithelium
  • Internal hemorrhoids:
    • Located above the dentate line
  • Both types of hemorrhoids often coexist.
  • Classification of internal hemorrhoids:
    • 1st-degree: Hemorrhoids do not prolapse.
    • 2nd-degree: Prolapse through the anus on straining but reduce spontaneously
    • 3rd-degree: Protrude and require digital reduction
    • 4th-degree: Cannot be reduced
  • Hemorrhoids often progress from itching, bleeding stage to protrusion with easy reduction, then difficult reduction, and finally rectal prolapse. Thrombosis may occur at any protrusion stage.

Geriatric Considerations
Common in elderly, along with rectal prolapse

Pediatric Considerations
  • Uncommon in infants and children. Look for underlying cause (e.g., venacaval or mesenteric obstruction, cirrhosis, portal HTN).
  • Occasionally, as in adults, hemorrhoids may result from chronic constipation, fecal impaction, and straining at stool. Surgery is rarely required in children.
Pregnancy Considerations
  • Common in pregnancy
  • Usually resolves after pregnancy
  • No treatment required, unless extremely painful

Epidemiology

  • Predominant age: Adults; peak between 45 and 65
  • Predominant sex: Male = Female

Incidence
Common

Prevalence
~4–5% in general population in the US

Risk Factors

  • Pregnancy
  • Pelvic space-occupying lesions
  • Liver disease
  • Portal HTN
  • Constipation
  • Occupations that require prolonged sitting
  • Loss of muscle tone in old age, rectal surgery, episiotomy, anal intercourse
  • Obesity
  • Chronic diarrhea

Genetics
No known genetic pattern

General Prevention

  • Avoid constipation with high-fiber diet and hydration.
  • Lose weight, if overweight.
  • Avoid prolonged sitting on the toilet.

Etiology

  • Dilated veins of hemorrhoidal plexus
  • Tight internal anal sphincter
  • Abnormal distention of the arteriovenous anastomosis
  • Prolapse of the cushions and the surrounding connective tissues

Commonly Associated Conditions

  • Liver disease
  • Pregnancy
  • Portal HTN
  • Constipation

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