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• W2165324208 abstract "The Lord will smite thee with … the emerods [hemorrhoids], and with the scab, and with the itch, whereof thou canst not be healed.Deuteronomy 28:27, King James Bible… and he smote the men of the city, both small and great, and they had emerods in their secret parts … and the men that died not were smitten with the emerods: and the cry of the city went up to heaven.Samuel 5:1, King James Bible Ancient references to symptomatic hemorrhoidal disease date back thousands of years and can be found in the Bible as well as early Egyptian, Babylonian, and Greek scripts.1Senagore A.J. Surgical management of hemorrhoids.J Gastrointest Surg. 2002; 6: 295-298Crossref PubMed Scopus (17) Google Scholar, 2Holley C.J. History of hemorrhoidal surgery.South Med J. 1946; 39: 536-541Crossref PubMed Scopus (17) Google Scholar, 3Kann B.R. Whitlow C.B. Hemorrhoids: diagnosis and management.Tech Gastrointest Endosc. 2004; 6: 6-11Abstract Full Text Full Text PDF Scopus (11) Google Scholar The first known mention of this condition is from an Egyptian papyrus in 1700 BC, which advises … “Thou shouldest give an ointment of acacia leaves, ground and titurated together … and place in the anus, that he recovers immediately.”4Wikipediahttp://en.wikipedia.org/wiki/HemorrhoidGoogle Scholar Indeed, there are few diseases more recounted in human history than hemorrhoids. The word hemorrhoid is derived from the Greek, with haima meaning blood and rhoos meaning flowing. Another common word for hemorrhoids used in the vernacular is “pile,” which comes from the Latin pila, meaning a ball. As aptly noted by Senagore, “although few people have died of hemorrhoidal disease, many patients who have undergone certain hemorrhoid therapies wish they had,” and this entity is one of the few diseases with its own patron saint (St Fiachre, the patron saint of gardeners and hemorrhoid sufferers).1Senagore A.J. Surgical management of hemorrhoids.J Gastrointest Surg. 2002; 6: 295-298Crossref PubMed Scopus (17) Google Scholar Symptomatic hemorrhoids are common, and those with hemorrhoids along with other anorectal diseases frequently present to the gastroenterologist with lower gastrointestinal (GI) bleeding and perianal complaints for evaluation and treatment. These patients and their referring physicians have an expectation that the gastroenterologist who examines this area should be able to provide comprehensive care of any nonsurgical anorectal ailments that are present. However, in large part because of the fact that formal training in anorectal pathology is not included in the combined Gastroenterology Core Curriculum, the care of these problems is often deferred to surgical specialties.5Di Palma J. Introducing comprehensive non-surgical anorectal care to the gastroenterology fellowship training curriculum: the University of South Alabama experience.Pract Gastroenterol. 2011; (May): 31-36Google Scholar, 6AASLD, ACG, AGA Institute, ASGEThe gastroenterology core curriculum.http://www.gastro.org/2007_Version_Core_Curriculum.pdfGoogle Scholar There now seems to be an increasing recognition of this gap in the training of gastroenterology fellows, because an increasing number of GI programs are beginning to include nonsurgical anorectal care into their curricula. Some have called for the formal inclusion of anorectal entities into GI fellowship training.5Di Palma J. Introducing comprehensive non-surgical anorectal care to the gastroenterology fellowship training curriculum: the University of South Alabama experience.Pract Gastroenterol. 2011; (May): 31-36Google Scholar It is the intent of this article to serve as a general introduction of the nonsurgical care of hemorrhoids to gastroenterologists, helping them provide a more complete continuum of care to their patients. The exact prevalence of symptomatic hemorrhoids is very difficult to establish, because many sufferers do not seek care for their problems or rely on over-the-counter remedies, whereas others attribute other anorectal symptoms as being a result of hemorrhoids.7Kaidar-Person O. Person B. Wexner S.D. Hemorrhoidal disease: a comprehensive review.J Am Coll Surg. 2007; 204: 102-117Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 8Guttenplan M. Ganz R.A. Hemorrhoids: office management and review for gastroenterologists.http://Touchgastroentorology.comGoogle Scholar, 9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar As noted in a recent American Gastroenterological Association review, the epidemiology of hemorrhoidal disease has been studied via different tools, each of which has methodologic limitations. Surveys that rely on patient self-reporting are nonspecific, and physician-reported diagnoses or hospital discharge data are not always confirmed. Thus, epidemiologic data can vary widely. Estimates of the prevalence of symptomatic hemorrhoid disease in the United States range from 10 million people, a 4.4% prevalence rate,10Johanson J.F. Sonnenberg A. The prevalence of hemorrhoids and chronic constipation: an epidemiologic study.Gastroenterology. 1990; 98: 380-386Crossref PubMed Google Scholar to a National Center for Health Statistics report of up to 23 million people or 12.8% of U.S. adults.11LeClere F.B. Moss A.J. Everhart J.E. et al.Prevalence of major digestive disorders and bowel symptoms, 1989.Adv Data. 1992; 212: 1-15PubMed Google Scholar Others have reported up to a 30%–40% prevalence rate in the United States.12Janicke D.M. Pundt M.R. Anorectal disorders.Emerg Med Clin North Am. 1996; 14: 757-788Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 13Ohning G.V. Machicado G.A. Jensen D.M. Definitive therapy for internal hemorrhoids: new opportunities and options.Rev Gastroenterol Disord. 2009; 9: 16-26PubMed Google Scholar A recent prospective study of screening colonoscopy patients revealed the presence of hemorrhoids in 38.9%, with 44.7% of those patients suffering from hemorrhoidal symptoms.14Riss S. Weiser F.A. Schwameis K. et al.The prevalence of hemorrhoids in adults.Int J Colorectal Dis. 2012; 27: 215-220Crossref PubMed Scopus (200) Google Scholar In 2004, the National Institutes of Health noted that the diagnosis of hemorrhoids was associated with 3.2 million ambulatory care visits, 306,000 hospitalizations, and 2 million prescriptions in the United States.15Everhart J.E. The burden of digestive diseases in the United States. National Institute of Diabetes and Digestive and Kidney Diseases, US Department of Health and Human Services, Bethesda, MD2008Google Scholar Although it has been stated that 50% of the population will experience symptomatic hemorrhoid disease at some point in their lives,16Baker H. Hemorrhoids.in: Longe J.L. Gale encyclopedia of medicine. 3rd ed. Gale, Detroit2006: 1766-1769Google Scholar the peak incidence of symptomatic disease seems to be between the ages of 45–65 years. Development of hemorrhoids before the age of 20 is unusual, and the risk is higher for whites than for blacks.10Johanson J.F. Sonnenberg A. The prevalence of hemorrhoids and chronic constipation: an epidemiologic study.Gastroenterology. 1990; 98: 380-386Crossref PubMed Google Scholar, 17Hulme-Moir M. Bartolo D.C. Hemorrhoids.Gastroenterol Clin North Am. 2001; 30: 183-197Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 18Ohning G.V. Machicado G.A. Jensen D.M. Definitive therapy for internal hemorrhoids: new opportunities and options.Rev Gastroenterol Disord. 2009; 9: 16-26PubMed Google Scholar Pregnancy is associated with an increased risk for hemorrhoids, and there is a slightly increased prevalence in women compared with men.9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 19Medich D.S. Fazio V.W. Hemorrhoids, anal fissure, and carcinoma of the colon, rectum and anus during pregnancy.Surg Clin North Am. 1995; 75: 77-78Abstract Full Text PDF PubMed Scopus (52) Google Scholar Neither chronic constipation nor portal hypertension has convincingly been linked to hemorrhoids.20Jacobs D.M. Bubrick M.P. Onstad G.R. et al.The relationship of hemorrhoids to portal hypertension.Dis Colon Rectum. 1980; 21: 567-569Crossref Scopus (61) Google Scholar, 21Johanson J.F. Sonnenberg A. The prevalence of hemorrhoids and chronic constipation: an epidemiology study.Gastroenterology. 1990; 98: 380-386Crossref PubMed Scopus (419) Google Scholar Hemorrhoids are commonly seen in patients with spinal cord injury.10Johanson J.F. Sonnenberg A. The prevalence of hemorrhoids and chronic constipation: an epidemiologic study.Gastroenterology. 1990; 98: 380-386Crossref PubMed Google Scholar, 22Stone J.M. Nino-Murcia M. Wolfe V.A. et al.Chronic gastrointestinal problems in spinal cord injury patients: a prospective analysis.Am J Gastroenterol. 1990; 85: 1114-1119PubMed Google Scholar, 23Delcò F. Sonnenberg A. Associations between hemorrhoids and other diagnoses.Dis Colon Rectum. 1998; 41: 1534-1541Crossref PubMed Google Scholar Why are hemorrhoids called hemorrhoids and asteroids called asteroids? Wouldn't it make more sense if it was the other way around? But if that were true, then a proctologist would be an astronaut.Robert Schimmel (1950–2010) The rectum extends from the terminal sigmoid colon to the anus, is lined by columnar epithelial mucosa innervated by the sympathetic and parasympathetic nervous systems, and consequently is relatively insensate. Its vascular and lymphatic supplies originate from the hypogastric system. The anal canal, which is approximately 4 cm in length, extends from the anal verge to its junction with the rectum close to the proximal aspect of the levator-sphincteric complex. Unlike the rectum, the anus is lined by anoderm, which is a modified and sensitive squamous epithelium richly innervated with somatic sensory nerves, and supplied by the inferior hemorrhoidal system.8Guttenplan M. Ganz R.A. Hemorrhoids: office management and review for gastroenterologists.http://Touchgastroentorology.comGoogle Scholar, 24Wexner S.D. Jorge J.M.N. Anatomy and embryology of the anus, rectum, and colon.in: Corman M.L. Colon and rectal surgery. Lippincott-Raven, Philadelphia, PA1998Google Scholar The dentate line is the point at which the squamous anoderm meets the columnar mucosa and typically lies about 3 cm above the anal verge.25Cleator I.G.M. Cleator M.M. Banding hemorrhoids using the O'Regan disposable bander.US Gastroenterology Review. 2005; 5: 69-73Google Scholar The dentate line is the major anatomic reference point when considering the treatment of hemorrhoids. Internal hemorrhoids are cushions of fibrovascular tissue located just proximal to the dentate line, with the external hemorrhoidal cushions lying distal to it. This terminology can seem a bit confusing, because in this context, the word external does not mean outside the anal canal, but rather distal to the dentate line; there are external hemorrhoids residing inside the anal verge (Figure 1). Work by Thomson,26Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Scopus (461) Google Scholar published in 1975, used both anatomic dissections along with radiologic and vascular studies to best elucidate hemorrhoidal anatomy. He noted that the submucosa in the area of the anal canal formed a discontinuous layer of thickened tissue, creating “cushions” typically found in the left lateral, right anterior, and right posterior positions, although there are frequent anatomic variations of this arrangement.9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 26Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Scopus (461) Google Scholar These cushions receive their blood supply primarily from the superior hemorrhoidal artery as well as branches of the middle hemorrhoidal arteries; however, there is some communication with the inferior hemorrhoidal arteries as well. The venous drainage is provided by the superior, middle, and inferior hemorrhoidal vessels, allowing for communication between the portal and systemic circulations. These vessels form direct arteriovenous communications within the cushions, and for these reasons, hemorrhoidal bleeding is arterial in nature rather than venous.26Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Scopus (461) Google Scholar The submucosal layer of these cushions contains not only the vessels mentioned above but is also rich in muscular fibers, which arise from both the internal sphincter and the conjoined longitudinal muscle. These muscular fibers (the muscularis submucosae) help to maintain adherence of these tissues to the underlying internal sphincter.26Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Scopus (461) Google Scholar, 27Sardinha T.C. Corman M.L. Hemorrhoids.Surg Clin North Am. 2002; 82: 1153-1167Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar With time and aging, starting as early as the second or third decade of life, this supporting tissue can deteriorate or weaken, leading to distal displacement of the cushions and venous distention, erosion, bleeding, and thrombosis and also allowing for tissue prolapse.3Kann B.R. Whitlow C.B. Hemorrhoids: diagnosis and management.Tech Gastrointest Endosc. 2004; 6: 6-11Abstract Full Text Full Text PDF Scopus (11) Google Scholar, 9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 26Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Scopus (461) Google Scholar, 28Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management.World J Gastroenterol. 2012; 18: 2009-2017Crossref PubMed Scopus (224) Google Scholar The hemorrhoidal cushions are considered to play an important role in the maintenance of rectal continence, contributing 15%–20% of the resting pressure of the anal verge. They also work to protect the sphincter mechanism during defecation, in addition to providing complete closure of the anal opening, especially while performing a Valsalva maneuver.26Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Scopus (461) Google Scholar, 29Lestar B. Penninck F. Kerremans R. The composition of anal basal pressure: an in vivo and in vitro study in man.Int J Colorectal Dis. 1989; 4: 118-122Crossref PubMed Scopus (244) Google Scholar, 30Loder P.B. Kamm M.A. Nicholls R.J. et al.Haemorrhoids: pathology, pathophysiology and aetiology.Br J Surg. 1994; 81: 946-954Crossref PubMed Scopus (253) Google Scholar Although hemorrhoidal cushions are normal anatomic structures, they are infrequently referred to until issues arise, and then the term hemorrhoid is meant as a pathologic process. The pathogenesis of hemorrhoids is not completely clear, but as stated by Kann et al,3Kann B.R. Whitlow C.B. Hemorrhoids: diagnosis and management.Tech Gastrointest Endosc. 2004; 6: 6-11Abstract Full Text Full Text PDF Scopus (11) Google Scholar “all etiologic factors work toward stretching and slippage of the hemorrhoidal tissue.” As the supporting tissue of the anal cushions weakens, downward displacement of the cushions can occur, causing venous dilation and prolapse.29Lestar B. Penninck F. Kerremans R. The composition of anal basal pressure: an in vivo and in vitro study in man.Int J Colorectal Dis. 1989; 4: 118-122Crossref PubMed Scopus (244) Google Scholar, 30Loder P.B. Kamm M.A. Nicholls R.J. et al.Haemorrhoids: pathology, pathophysiology and aetiology.Br J Surg. 1994; 81: 946-954Crossref PubMed Scopus (253) Google Scholar There is some controversy regarding the pathogenesis of symptomatic hemorrhoids, as Thomson26Thomson W.H. The nature of haemorrhoids.Br J Surg. 1975; 62: 542-552Crossref PubMed Scopus (461) Google Scholar and Corman31Corman M.L. Hemorrhoids.in: Corman M.L. Colon and rectal surgery. 4th ed. Lippincott-Raven, Philadelphia, PA1998: 147-205Google Scholar propose the following possibilities:1Deterioration of the anchoring connective tissue, as described by Thomson.2Downward displacement or prolapse of the hemorrhoidal tissue.3Abnormal distention of the arteriovenous anastomoses within the cushions.4Abnormal dilatation of the veins of the internal hemorrhoidal venous plexus. Any number of possible contributing factors leading to migration of the hemorrhoidal cushions has been suggested, including lack of dietary fiber, chronic straining, spending excess time on the commode, constipation, diarrhea, pregnancy, sedentary lifestyle, and a family history. Apart from pregnancy, none of these etiologies are supported by good evidence.9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 30Loder P.B. Kamm M.A. Nicholls R.J. et al.Haemorrhoids: pathology, pathophysiology and aetiology.Br J Surg. 1994; 81: 946-954Crossref PubMed Scopus (253) Google Scholar Others have discussed the role of pelvic floor dysfunction, particularly as that relates to elevated anal sphincter pressure, which has been demonstrated in some patients with symptomatic hemorrhoids. However, it is not clear whether these pressure changes are the cause or the result of hemorrhoids.27Sardinha T.C. Corman M.L. Hemorrhoids.Surg Clin North Am. 2002; 82: 1153-1167Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 32Deutsch A.A. Moshkovitz M. Nudelman I. et al.Anal pressure measurements in the study of hemorrhoid etiology and their relation to treatment.Dis Colon Rectum. 1987; 30: 855-857Crossref PubMed Scopus (48) Google Scholar, 33Sun W.M. Read N.W. Shorthouse A.J. Hypertensive anal cushions as a cause of the high anal canal pressures in patients with haemorrhoids.Br J Surg. 1990; 77: 458-462Crossref PubMed Scopus (56) Google Scholar As the overlying skin or mucosa is stretched, additional fibrous and sinusoidal tissue develops. With time, the anatomic structures supporting the muscularis submucosae weaken, leading to continued slippage and prolapse. As the redundant tissue moves toward the anal verge, it becomes susceptible to injury and allows symptoms to develop11LeClere F.B. Moss A.J. Everhart J.E. et al.Prevalence of major digestive disorders and bowel symptoms, 1989.Adv Data. 1992; 212: 1-15PubMed Google Scholar (Figure 2). The majority of hemorrhoidal symptoms arise from enlarged internal hemorrhoids, with bleeding as the most common presenting symptom.9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar As internal hemorrhoids prolapse through the anal canal, the tissue can become traumatized and friable, leading to bleeding. Hemorrhoids are arteriovenous plexuses, so the bleeding is typically bright red in color.9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 28Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management.World J Gastroenterol. 2012; 18: 2009-2017Crossref PubMed Scopus (224) Google Scholar Blood that is darker in color suggests other, more proximal sources. Bleeding can be identified on the toilet paper or in the toilet bowl, is typically not mixed with stool, can drip or squirt out, and can be exacerbated by straining.12Janicke D.M. Pundt M.R. Anorectal disorders.Emerg Med Clin North Am. 1996; 14: 757-788Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 27Sardinha T.C. Corman M.L. Hemorrhoids.Surg Clin North Am. 2002; 82: 1153-1167Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Hemorrhoids typically do not cause a positive Hemoccult test by themselves.9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 34Nakama H. Kamijo N. Fujimori K. et al.Immunochemical fecal occult blood test is not suitable for diagnosis of hemorrhoids.Am J Med. 1997; 102: 551-554Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 35Korkis A.M. McDougall C.J. Rectal bleeding in patients less than 50 years of age.Dig Dis Sci. 1995; 40: 1520-1523Crossref PubMed Scopus (45) Google Scholar Internal hemorrhoids are covered with columnar mucosa, leading to mucous deposition on the perianal skin, which can also cause itching and perineal irritation. The prolapsing tissue can also impede the ability of the anal verge to “seal,” and so fecal soiling can be noted as well.8Guttenplan M. Ganz R.A. Hemorrhoids: office management and review for gastroenterologists.http://Touchgastroentorology.comGoogle Scholar Internal hemorrhoids originate from points proximal to the dentate line and are covered by relatively insensate mucosa, so they are typically not painful. Internal hemorrhoids also rarely thrombose.9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar Hemorrhoid-associated pain usually comes from thrombosed external hemorrhoids, which can present as an acutely painful perianal swelling. External hemorrhoids are otherwise typically asymptomatic. With this in mind, if pain is one of the patient's symptoms, then it is recommended to look for coexistent complicating issues that may be the cause of perianal pain. These associated factors include entities such as anal fissures, solitary rectal ulcer syndrome, and a host of issues dealing with pelvic floor dysfunction (internal sphincter spasm, pelvic dyssynergia, proctalgia fugax, etc).8Guttenplan M. Ganz R.A. Hemorrhoids: office management and review for gastroenterologists.http://Touchgastroentorology.comGoogle Scholar Internal hemorrhoids have been staged or graded on the basis of their severity. The classification of Banov et al36Banov L. Knoepp L.F. Erdman L.H. et al.Management of hemorrhoidal disease.J S C Med Assoc. 1985; 81: 398-401PubMed Google Scholar is based on the degree of hemorrhoidal prolapse during defecation (Table 1 and Figure 3). Hemorrhoids can also be classified by their location.31Corman M.L. Hemorrhoids.in: Corman M.L. Colon and rectal surgery. 4th ed. Lippincott-Raven, Philadelphia, PA1998: 147-205Google Scholar Mixed hemorrhoids arise from both the internal and external plexuses along with their anastomotic connections (Figure 4).7Kaidar-Person O. Person B. Wexner S.D. Hemorrhoidal disease: a comprehensive review.J Am Coll Surg. 2007; 204: 102-117Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar, 8Guttenplan M. Ganz R.A. Hemorrhoids: office management and review for gastroenterologists.http://Touchgastroentorology.comGoogle ScholarTable 1Grades and Types of HemorrhoidsGrades of internal hemorrhoids (Banov36Banov L. Knoepp L.F. Erdman L.H. et al.Management of hemorrhoidal disease.J S C Med Assoc. 1985; 81: 398-401PubMed Google Scholar) INonprolapsing internal hemorrhoids IIInternal hemorrhoids prolapse during defecation, spontaneously reduce IIIInternal hemorrhoids prolapse during defecation, must be manually reduced IVInternal hemorrhoids prolapsed and incarceratedTypes of hemorrhoids InternalCovered by columnar epithelium, Figure 2 ExternalCovered by squamous epithelium (anoderm), Figure 2 Mixed hemorrhoidsInvolving and bridging both of the above spaces, Figure 4 Open table in a new tab Figure 4Illustration of a “mixed” hemorrhoid involving the internal, external, and bridging spaces.Courtesy of Iain Cleator, MD, Vancouver, BC, Canada.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Patients presenting with most anorectal symptoms will often assume that they are due to hemorrhoids.27Sardinha T.C. Corman M.L. Hemorrhoids.Surg Clin North Am. 2002; 82: 1153-1167Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar Keeping this in mind, it is always important to determine whether the patient's symptoms are due to hemorrhoids, some other anorectal disorder, or a combination thereof. The symptoms, in large part, depend on the location of the hemorrhoidal changes in relation to the dentate line. Internal hemorrhoids are located proximal to (above) the dentate line and tend to be associated with painless bleeding, prolapse, mucus discharge, soiling, and symptoms of pruritus ani. Perceived incontinence or soiling can be caused by prolapsed hemorrhoids that create a “wicking effect” by which anal content may seep out. Internal hemorrhoids rarely cause significant pain unless they become prolapsed, incarcerated, and begin developing gangrenous changes. On the other hand, external hemorrhoids are typically asymptomatic unless they become thrombosed.27Sardinha T.C. Corman M.L. Hemorrhoids.Surg Clin North Am. 2002; 82: 1153-1167Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 37Halverson A. Hemorrhoids.Clin Colon Rectal Surg. 2007; 20: 77-85Crossref PubMed Scopus (19) Google Scholar Mixed hemorrhoids involve areas both above and below the dentate line and can present with bleeding, pain, or other symptoms18Ohning G.V. Machicado G.A. Jensen D.M. Definitive therapy for internal hemorrhoids: new opportunities and options.Rev Gastroenterol Disord. 2009; 9: 16-26PubMed Google Scholar (Figure 4). A detailed history is mandatory in patients presenting with symptoms consistent with hemorrhoidal disease. Significant anal pain could come from other entities, and in this regard the timing of the pain is important. Acute onset of pain associated with perianal swelling suggests a thrombosed external hemorrhoid, but pain on defecation typically indicates the presence of a coexistent anal fissure, which can be found in up to 20% of hemorrhoid patients.38Schubert M.C. Sridhar S. Schade R.R. et al.What every gastroenterologist needs to know about common anorectal disorders.World J Gastroenterol. 2009; 15: 3201-3209Crossref PubMed Scopus (75) Google Scholar This may be related to findings that patients with hemorrhoids tend to have higher resting anal sphincter pressures than those without. It is not clear whether these elevated pressures are the cause or the result of the associated hemorrhoids, but the relationship does seem consistent.37Halverson A. Hemorrhoids.Clin Colon Rectal Surg. 2007; 20: 77-85Crossref PubMed Scopus (19) Google Scholar, 39Hancock B.D. Internal sphincter and the nature of haemorrhoids.Gut. 1977; 18: 651-655Crossref PubMed Scopus (80) Google Scholar Other pain-associated entities to consider include inflammatory bowel disease with proctitis or perirectal fistula or abscess, anal warts, rectal cancers, anal polyps, or solitary rectal ulcer syndrome.8Guttenplan M. Ganz R.A. Hemorrhoids: office management and review for gastroenterologists.http://Touchgastroentorology.comGoogle Scholar, 9Madoff R.D. Fleshman J.W. Clinical Practice Committee and American Gastroenterological Association: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids.Gastroenterology. 2004; 126: 1463-1473Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar Additional information that may be of importance includes the relationship between symptoms and defecation and a description of factors that might either relieve or exacerbate a patient's symptoms. There may be value in finding out how often a patient defecates, whether constipation or diarrhea is an issue, how much time they spend on the commode, and whether they must manually reduce their hemorrhoids after defecation.3Kann B.R. Whitlow C.B. Hemorrhoids: diagnosis and management.Tech Gastrointest Endosc. 2004; 6: 6-11Abstract Full Text Full Text PDF Scopus (11) Google Scholar It is also important to ask about soiling or incontinence because many patients may be hesitant to discuss this. Rectal bleeding should never be assumed to be from hemorrhoids without at least some type of" @default.
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• W2165324208 date "2013-06-01" @default.
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• W2165324208 title "The Evaluation and Treatment of Hemorrhoids: A Guide for the Gastroenterologist" @default.
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