Hemorrhoids overview

# Overview
Hemorrhoids are varicosities or swelling and inflammation of veins in the rectum and anus. The rectum is the last part of the large intestine leading to the anus. The anus is the opening at the end of the digestive tract where bowel contents leave the body.
External hemorrhoids are located under the skin around the anus. Internal hemorrhoids develop in the lower rectum. Internal hemorrhoids may protrude, or prolapse, through the anus. Most prolapsed hemorrhoids shrink back inside the rectum on their own. Severely prolapsed hemorrhoids may protrude permanently and require treatment.

# Historical Perspective
Hemorrhoids were first discovered by ancient Egyptians more than 3,700 years ago.

# Classification
Hemorrhoids can be classified according to their location as external or internal hemorrhoids. Furthermore, internal hemorrhoids can be graded according to severity into 4 grades.

# Pathophysiology
Hemorrhoids develop due to a combination of genetic predisposition (weak rectal veins) and certain diet and defecation habits.

# Causes
Hemorrhoids may be caused by factors that increase the pressure in the rectal veins such as chronic cough, chronic constipation, and straining.

# Differentiating Hemorrhoids from other Diseases
Hemorrhoids should be differentiated from other diseases that cause anal discomfort and pain with defecation such as rectal cancer, anal fissure, anal abscess, and anal fistula.

# Epidemiology and Demographics
In the USA, the prevalence of hemorrhoids is about 4.4%. Only about 500,000 patients in the U.S. are medically treated for massive hemorrhage, with 10 to 20% requiring surgery.

# Risk Factors
Common risk factors in the development of hemorrhoids are excessive straining, sitting or standing for long periods of time, pregnancy, and chronic constipation.

# Screening
According to the USPSTF, screening for hemorrhoids is not recommended.

# Natural History, Complications, and Prognosis
If left untreated, hemorrhoids may lead to strangulation, anemia, or fecal incontinence. Common complications of hemorrhoids include secondary infection, thrombosis, or strangulation. Prognosis is generally excellent and most cases respond to non surgical treatment. However, surgery gives the best prognosis with the least recurrence rate.

# Diagnosis

## History and Symptoms
Symptoms of hemorrhoids include pain with defecation, hematochezia, and anal discharge.

## Physical Examination
Patients with acute prolapsed or thrombosed hemorrhoids usually appear ill and in pain. Physical examination of patients with hemorrhoids is usually remarkable for protruding mass from the anus or palpable mass on digital rectal exam.

## Laboratory Findings
There are no specific diagnostic lab findings associated with hemorrhoids. However, complete blood count may show anemia in the case of chronic bleeding.

## Imaging Findings
There are no X-ray, MRI or ultrasound findings associated with hemorrhoids.

## Other Imaging Finidings
There are no other diagnostic imaging studies of significance for hemorrhoids.

## Other Diagnostic Studies
Anoscopy is mandatory to visualize internal hemorrhoids as they are not visible on inspection of the anal verge or palapable on performing digital rectal exam.

# Treatment

## Medical Therapy
There is no medical treatment for hemorrhoids. Medical therapy aims to provide symptomatic relief from constipation. Local treatments such as warm sitz baths, cold compress, and topical analgesic (such as nupercainal) can provide temporary relief.

## Surgery
Surgery is not the first-line treatment option for patients with hemorrhoids. Surgical intervention is usually reserved for patients with either complicated or large hemorrhoids (beyond grade III).

## Primary Prevention
Primary prevention of hemorrhoids may include drinking excessive fluids, regular exercise, practicing better posture, and reduction of bowel movement straining and time. Eating a high-fiber diet can make stools softer and easier to pass, reducing the pressure on hemorrhoids caused by straining.

## Secondary Prevention
The secondary preventive measures for hemorrhoids are similar to primary preventive measures.