Sandbox: hemorrhoids

## High fiber diet
- Eating a high-fiber diet can make stools softer and easier to pass, reducing the pressure on hemorrhoids caused by straining.
- Fiber is not digested in the GIT, but it helps improving digestion and preventing constipation.
- Good sources of dietary fiber are fruits, vegetables, and whole grains.
- On average, Americans eat about 15 grams of fiber each day while  the American Dietetic Association recommends 25 grams of fiber per day for women and 38 grams of fiber per day for men.3
- Bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel) may be useful in the management.

## Topical analgesics
- Lidocaine ointment 5% is used to relieve pain associated with complicated hemorrhoids.
- Lidocaine relieves pain through blocking Na channels in the sensory nerve endings thus inhibiting the propagation of the pain impulse.

## Topical anti-inflammatory
- Topical anti inflammatory agents mixed with cortisone may be used to relieve inflammation and shrink the size of the hemorrhoids.
- Cortisone containing agents should not be used more than one month as prolonged use may be associated with depressed local immunity and the development of skin tags.

## Sitz baths
- Sitz baths can be helpful in alleviating pruritus

## Hydroxyethylrutoside
- Hydroxyethylrutoside is a venotonic agent that increases the tone in the rectal veins, improves the venous and lymphatic flow and thus improves the symptoms and decreases the incidence of bleeding.

## Antispasmodics
- Local nitroglycerin can be used to alleviate the spasm associated with the pain

# Pathophysiology
- Hemorrhoids can be internal and external.
- Internal hemorrhoids are located above the dentate line and they occur due to dilatation of the superior hemorrhoidal plexus.
- The connective tissue over the superior hemorrhoidal plexus is innervated via visceral nerves and thus it is pain insensitive.
- External hemorrhoids are located below the dentate line and occur due to dilatation of the inferior hemorrhoidal plexus.
- The first step in the pathogenesis of either type of hemorrhoids is weakening of the surrounding connective tissue and vein wall. All the risk factors (old age, pregnancy, portal hypertension, etc) lead to aggravating this weakness or add more pressure from within the vein.
- Increased tone of the internal anal sphincter causing the feces to press the hemorrhoid against the muscle and thus decreasing venous return and aggravating the symptoms.
- The arteriovenous anastomosis may play a role in the development of hemorrhoids. This is supported by the fact that some hemorrhoids improve after ligating the connecting arteries.
- The redundant bulging mucosa is easily injured causing bleeding. The blood is usually bright red reflecting high oxygen content due to the proximity of AV anastomosis.

## Food
- Chronic constipation can cause hemorrhoidal irritation due to hard stools.
- An excess of lactic acid in the stool, a product of excessive consumption of dairy products such as cheese, can cause irritation. A reduction of consumption of these foods can bring relief.
- Vitamin E deficiency is also a common cause.
- Consuming probiotic foods such as yogurt with active culture or consuming fruit may help keep the gut functioning normally and prevent flare-ups.

## Use of unnatural "sitting" toilets
- Based on their very low incidence in the developing world, where people squat for bodily functions, hemorrhoids have been attributed to the use of the unnatural "sitting" toilet.
- In 1987, an Israeli physician, Dr. Berko Sikirov, published a study testing this hypothesis by having hemorrhoid sufferers convert to squat toilets. Eighteen of the 20 patients were completely relieved of their symptoms (pain and bleeding) with no recurrence, even 30 months after completion of the study.
- No follow-up studies have ever been published.
- The American Society of Colon & Rectal Surgeons has not published any recommendations regarding the therapeutic value of squatting.