Hemorrhoid

In about 40% of people with pathological hemorrhoids, there are no significant symptoms. Internal hemorrhoids are usually painful only if they become thrombosed or necrotic. ==Causes==

The exact cause of symptomatic hemorrhoids is unknown. Evidence for these associations, however, is poor. During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures. Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery. A personal history of hemorrhoids or anal fissures, constipation, prolonged straining during delivery, and delivering a larger baby (weighing over 3,800 grams) are risk factors for hemorrhoids during pregnancy and in the post-partum period. ==Pathophysiology==

of hemorrhoids, showing engorged blood vessels Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes. There are three main cushions present in the normal anal canal. These are located classically at left lateral, right anterior, and right posterior positions. They are composed of neither arteries nor veins, but blood vessels called sinusoids, connective tissue, and smooth muscle. Sinusoids do not have muscle tissue in their walls, as veins do. This set of blood vessels is known as the hemorrhoidal plexus. Hemorrhoid cushions are important for continence. They contribute to 15–20% of anal closure pressure at rest and protect the internal and external anal sphincter muscles during the passage of stool. When a person bears down, the intra-abdominal pressure grows, and hemorrhoid cushions increase in size, helping maintain anal closure. Hemorrhoid symptoms are believed to result when these vascular structures slide downwards or when venous pressure is excessively increased. Increased internal and external anal sphincter pressure may also be involved in hemorrhoid symptoms. Two types of hemorrhoids occur: internals from the superior hemorrhoidal plexus and externals from the inferior hemorrhoidal plexus. The pectinate line divides the two regions, and is also used to divide internal from external hemorrhoids. ==Diagnosis==

Hemorrhoids are typically diagnosed by physical examination. A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids. Visual confirmation of internal hemorrhoids, on the other hand, may require anoscopy, insertion of a hollow tube device with a light attached at one end. A digital rectal exam (DRE) can also be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses. If pain is present, the condition is more likely to be an anal fissure or external hemorrhoid rather than internal hemorrhoid. Internal Internal hemorrhoids originate above the pectinate line. They are covered by columnar epithelium, which lacks pain receptors. They were classified in 1985 into four grades based on the degree of prolapse: • Grade I: No prolapse, just prominent blood vessels • Grade II: Prolapse upon bearing down, but spontaneous reduction • Grade III: Prolapse upon bearing down requiring manual reduction • Grade IV: Prolapse with inability to be manually reduced. External external hemorrhoid External hemorrhoids occur below the dentate (or pectinate) line. They are covered proximally by anoderm and distally by skin, both of which are sensitive to pain and temperature. Differential Many anorectal problems, including fissures, fistulae, abscesses, colorectal cancer, rectal varices, and itching have similar symptoms and may be incorrectly referred to as hemorrhoids. Rectal bleeding may also occur owing to colorectal cancer, colitis including inflammatory bowel disease, diverticular disease, and angiodysplasia. If anemia is present, other potential causes should be considered. Rectal bleeding without bowel movements is unlikely to be due to hemorrhoids. Other conditions that produce an anal mass include skin tags, anal warts, rectal prolapse, polyps, and enlarged anal papillae. Anorectal varices due to portal hypertension (blood pressure in the portal venous system) may present similar to hemorrhoids but are a different condition. Portal hypertension does not increase the risk of hemorrhoids. ==Prevention==

A number of preventative measures are recommended, including avoiding straining while attempting to defecate, avoiding constipation and diarrhea either by eating a high-fiber diet and drinking plenty of fluid or by taking fiber supplements and getting sufficient exercise. Spending less time attempting to defecate, avoiding reading while on the toilet, ==Management==

Conservative Conservative treatment typically consists of foods rich in dietary fiber, intake of oral fluids to maintain hydration, nonsteroidal anti-inflammatory drugs, sitz baths, and rest. and may be achieved by dietary alterations or the consumption of fiber supplements. If they are used, they should be limited to 15 minutes at a time. While many topical agents and suppositories are available for the treatment of hemorrhoids, little evidence supports their use. Flavonoids are of questionable benefit, with potential side effects. Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery. Evidence does not support the use of traditional Chinese herbal treatment. The use of phlebotonics has been investigated in the treatment of low-grade hemorrhoids with a Cochrane review showing improvement in overall symptoms, including bleeding and itching. However there were no improvements in pain. The authors noted that more research was needed on the role of phlebotonics in the management of hemorrhoids. Procedures A number of office-based procedures may be performed. While generally safe, rare serious side effects such as perianal sepsis may occur. Infrared cauterization may be an option for grade I or II disease. HAE involves the blockage of abnormal blood flow to the rectal (hemorrhoidal) arteries using microcoils and/or microparticles to decrease the size of the hemorrhoids and improve hemorrhoid related symptoms, especially bleeding. HAE is very effective at stopping bleeding related symptoms with success rate of approximately 90%. Overall, the effectiveness of HAE is comparable to or better than surgery or transanal procedures. The frequency and severity of any potential adverse events are also significantly lower in HAE compared to surgery or transanal procedures. with rates reported between 0% and 28%. Mucosal ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis). This is where the anal mucosa becomes everted from the anus, similar to a very mild form of rectal prolapse. It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24–72 hours. Evidence to support this is weak, however. Excisional hemorrhoidectomy is the preferred method of surgical hemorrhoid removal. so it is typically recommended only for grade II or III disease. ==Epidemiology==

It is difficult to determine how common hemorrhoids are as many people with the condition do not see a healthcare provider. However, symptomatic hemorrhoids are thought to affect at least 50% of the US population at some time during their lives, and around 5% of the population is affected at any given time. Long-term outcomes are generally good, though some people may have recurrent symptomatic episodes. Only a small proportion of persons end up needing surgery. ==History==

The first known mention of this disease is from a 1700 BC Egyptian papyrus, which advises: "Thou shouldest give a recipe, an ointment of great protection; acacia leaves, ground, titurated and cooked together. Smear a strip of fine linen there-with and place in the anus, that he recovers immediately." The Susruta Samhita (4th–5th century BC) is similar to the words of Hippocrates, but emphasizes wound cleanliness. In the 13th century, European surgeons such as Lanfranc of Milan, Guy de Chauliac, Henri de Mondeville, and John of Ardene made great progress and development of the surgical techniques. The first use of the word hemorrhoid in English occurs in 1398, derived from the Old French , from Latin , in turn from the Greek (), , from (), and (), , itself from (), . ==Notable cases==

• Hall-of-Fame baseball player George Brett was removed from a game in the 1980 World Series due to hemorrhoid pain. After undergoing minor surgery, Brett returned to play in the next game, quipping, "My problems are all behind me". Brett underwent further hemorrhoid surgery the following spring. • Conservative political commentator Glenn Beck underwent surgery for hemorrhoids, subsequently describing his unpleasant experience in a widely viewed 2008 YouTube video. • Former U.S. President Jimmy Carter had surgery for hemorrhoids in 1984. • Cricketers Matthew Hayden and Viv Richards have suffered the condition. • During World War II, US Army Lieutenant Colonel Harold Cohen was selected by General George S. Patton to organize a raid to rescue Patton's son-in-law from a German prison camp; Cohen was prevented from leading the raid due to hemorrhoids. Patton personally examined Cohen and remarked, "that is some sorry ass". ==References==