HemorrhoidsHemorrhoids are dilated, twisted (varicose) veins

located in the wall of the rectum and anus.

Hemorrhoids occur when the veins in the rectum or anus become enlarged; they may eventually bleed.

Hemorrhoids may also become inflamed or may develop a blood clot (thrombus).

They are also known as piles.

The vessels of the anal cushions swell and the supporting tissues increase in size.

Hemorrhoids are common. By age 50, about half of adults have had to deal with the itching, bleeding and pain that often signal the presence of hemorrhoids.

Fortunately, effective medications and procedures are readily available to treat hemorrhoids. In many cases hemorrhoids may require only self-care and lifestyle changes.

Abnormally distended vein located either in the rectum or in the outer area surrounding the anal opening.

AnatomyThe dentate line delineates where nerve

fibers end.

Above this line, this area is relatively insensitive to pain.

Below the dentate line, the anal canal and anus are extremely sensitive.

TypesThere are 2 types of hemorrhoids:-

Internal hemorrhoidsExternal hemorrhoids

Hemorrhoids that form above the boundary between the rectum and anus (anorectal junction) are called internal hemorrhoids.

Those that form below the anorectal junction are called external hemorrhoids.

Both internal and external hemorrhoids may remain in the anus or protrude outside the anus.

The Liver and HemorrhoidsBy Looking at the venous return for the

external and internal hemorrhoidal veins, the following is observed:

External – pours into the systemic circulation

Internal - pours into portal veins

EtiologyMost common cause - constipationProlonged strainingPregnancyHeredityIncreased intra-abdominal pressureAging (due to thinning of supportive tissue)Chronic diarrhea.ObesityColon CancerRectal SurgeryRectal intercourse

Generalized SymptomsPainless bleeding. Most common symptom. Blood

is bright redMucosal protrusionDischargeSoiled underwear - due to prolapseSensation of incomplete evacuationPainDiscomfort, pruritis, burning sensation.

Symptoms - external hemorrhoidsExternal hemorrhoids, because they lie

under the skin are usually very painful

Result in tender blue swelling at the anal verge due to thrombosis of a vein in the external plexus - need not be associated with enlargement of the internal veins

Spasm often occurs since the thrombus usually lies at the level of the sphincteric muscles

Conditions that mimic hemorrhoids

Anal abscessCryptitisAnal fissureInflammatory bowel diseaseRectal polypsColorectal cancers

June 22, 2011 — The US Food and Drug Administration (FDA) has approved nitroglycerin ointment 0.4% (Rectiv, ProStrakan Group) for the treatment of moderate to severe pain associated with chronic anal fissures

ClassificationMost clinicians use the grading system proposed by Banov et al in

1985, which classifies internal hemorrhoids by their degree of prolapse into the anal canal. This system both correlates with symptoms and guides therapeutic approaches.

Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse.

Grade II hemorrhoids may protrude beyond the anal verge with straining or defecating but reduce spontaneously when straining ceases.

Grade III hemorrhoids protrude spontaneously or with straining and require manual reduction.

Grade IV hemorrhoids chronically prolapse and cannot be reduced. They usually contain both internal and external components and may present with acute thrombosis or strangulation.

PathophysiologyForm due to excessive pressure in the rectal

area, which causes the walls of nearby veins to distend.

As the result of an increased influx of blood.

If an internal hemorrhoid is left untreated, it may swell to such an extent that it is forced outside of the anal opening, becoming prolapsed hemorrhoid.

If the blood supply to the hemorrhoid is blocked by the sphincter muscle, resulting in a strangulated hemorrhoid.

Rupture of the distended vein and the formation of a blood clot caused thrombosed hemorrhoid.

Prolapsed hemorrhoid

DiagnosisAnoscopySigmoidoscopyColonoscopy

Complications ThrombosisSecondary infectionUlcerationAbscessIncontinenceStenosisNonhealing wounds

TreatmentFor 1st and 2nd grades:

Reduce strainingCorrection of constipationEpsom salt bathsOTC hemorrhoidal ointments, creams, foams

and suppositories

For higher-grade internal hemorrhoidsHemorrhoidal bandingSurgical hemorrhoidectomy

Hemorrhoidectomy

Internal hemorrhoid

External hemorrhoidHemorrhoid massSkin and tissues

Gauze swab Hemorrhoid

Anus

Sutures

OTC medicationsAnalgesics and local anestheticsAstringentsProtectantsVasoconstrictorsKeratolyticsHydrocortisoneWound healing agents

Astringents

Astringents reduce the swelling of the affected tissues by shrinking them. They also act to decrease mucous and other secretions. This way, astringents reduce hemorrhoidal symptoms like inflammation, burning, and itching. However, they do not relive pain.

Calamine, witch hazel (hamamelis water), and zinc oxide are the most commonly used astringents for hemroid treatment.

Protectants

Protectants are a type of over the counter hemorrhoid medications that reduces inflammation by forming a protective barrier over the skin and mucous membrane. Protectants also prevent stratum corneum (topmost skin layer) from losing water.

A number of protectants are employed in over the counter hemorrhoidal medication, e.g. aluminum hydroxide (in gel form), glycerin (water solution), cocoa butter, mineral oil, kaolin, and petrolatum etc.

Vasoconstrictors

Vasoconstrictors are a group of over the counter hemorrhoid medications that work to reduce swelling by causing the blood vessels to constrict. They also have a slightly anesthetic effect on the blood vessels. These enable vasoconstrictors to provide relief from itching, irritation, and discomfort of the affected tissues. Vasoconstrictors are not usually recommended for people with blood pressure problems and heart diseases because the chemical agents in these products can raise blood pressure and cause abnormal heartbeat along with a range of other side effects.

Local Anesthetics

By blocking the nerves from conducting messages of pain, burning, itching, and irritation, local anesthetics provide temporary relief from these hemorrhoid symptoms.

Local anesthetics are mostly used for external hemorrhoids only and include such chemical agents as Benzocaine, Benzyl alcohol, Dibucaine, and Lidocaine.

Keratolytics

Keratolytics are yet another type of over the counter hemroid medication. Keratolytics act to dissolve skin flakes and scales (peel off the skin), which enables the affected tissues to better absorb other topical medication for hemorrhoids.

This way, Keratolytics reduce itching and irritation associated with the condition. Examples of Keratolytics include Alcloxa and Resorcinol.

Lidocaine ointment 5% (Lidoderm, Dermaflex): Indicated for PAIN & ITCHING

Decreases permeability to sodium ions in neuronal membranes, resulting in inhibition of depolarization, blocking transmission of nerve impulses.

Dosing Adult Apply to affected area prn Pediatric Apply as in adultsInteractions None reportedContraindications Documented hypersensitivityPrecautions Pregnancy B - Fetal risk not confirmed in studies in humans but has been shown

in some studies in animals. For external or mucous membrane use only; do not use in eyes.

Hamamelis water (Witch Hazel)Mild astringent prepared from twigs of Hamamelis

virginiana, used to temporarily relieve itching of hemorrhoids.

DosingAdultApply locally up to 6 times/d or following a bowel

movementPediatricNot establishedInteractionsNone reportedContraindicationsDocumented hypersensitivityPrecautionsPregnancy: A - Fetal risk not revealed in controlled

studies in humansFor external use only; avoid contact with eyes; discontinue

treatment if condition worsens

Diosmin & Flavonid Expressed In Hespiridin

Some clinicians use diosmin in lower doses and in combination with bulk laxatives instead of hesperidin. Diosmin 600 mg three times daily for 4 days, then 300 mg twice daily for 10 more days plus the bulk laxative psyllium 11 grams daily does seem to slightly help after 4 days of treatment.

However, this combination does not seem to be as effective as the higher dose of diosmin plus hesperidin combination. Maintenance use of diosmin 450 mg plus hesperidin 50 mg twice daily for 3 months in patients following acute treatment for internal hemorrhoids seems to significantly decrease the relapse rate.