Contents

Search

hemorrhoids (piles)

Classification: - external hemorrhoids; occur below the dentate line (pectinate line) - internal hemorrhoids: occur above the dentate line - grade 1: do not prolapse - grade 2; prolapse with straining but have spontaneous reduction - grade 3: require manual reduction of the hemorrhoid - grade 4: not manually reducible [7] Etiology: - enlarged veins within the rectum (internal) or around the perianal region (external) Pathology: - collections of submucosal, fibrovascular, arteriovenous sinusoids, that are part of the normal anorectum [2] - vascular cushions that support the muscle of the anal sphincter by swelling up as needed to support stool continence - prolapsed hemorrhoids are internal hemorrhoids that protrude out of the rectum [2] Clinical manifestations: - may be associated with hematochezia or BRBPR [6] Differential diagnosis: 1) pruritus ani 2) anal fissure 3) abscess 4) fistula 5) internal hemorrhoids 6) external hemorrhoids Management: - dietary & lifestyle measure to soften stool (first line grade 1 & 2) [7] - adequate fluids - increased dietary fiber - exercise - phlebotonics may be of benefit [5] - avoid constipation, straining & prolonged time on toilet - stool softener, laxative as needed (see constipation) - hemorrhoidectomy with office-based hemorrhoidal banding when medical therapy inadequate [5]

Specific

external hemorrhoids internal hemorrhoids

General

varicose vein (varix) chronic gastrointestinal disease

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 353-54
  2. Jacobs D Hemorrhoids. N Engl J Med 2014; 371:944-951. September 4, 2014 PMID: 25184866 http://www.nejm.org/doi/full/10.1056/NEJMcp1204188
  3. Medical Knowledge Self Assessment Program (MKSAP) 17, 18, 19. American College of Physicians, Philadelphia 2015, 2018. 2021.
  4. Rivadeneira DE, Steele SR, Ternent C et al Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum. 2011 Sep;54(9):1059-64 PMID: 21825884 (corresponding NGC guideline withdrawn Nov 2016)
  5. Davis BR, Lee-Kong SA, Migaly J et al The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Diseases of the Colon & Rectum: March 2018. 61(3):284-292 PMID: 29420423 https://journals.lww.com/dcrjournal/Fulltext/2018/03000/The_American_Society_of_Colon_and_Rectal_Surgeons.7.aspx
  6. NEJM Knowledge+ Gastroenterology
  7. Wald A, Bharucha AE, Limketkai B et al ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. 2021 Oct 1;116(10):1987-2008. PMID: 34618700
  8. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) Hemorrhoids https://www.niddk.nih.gov/health-information/digestive-diseases/hemorrhoids