Today hemorrhoids remain the most common anorectal disorder and are frequently seen in primary care clinics, emergency wards, gastroenterology units, and surgical clinics

Pathophysiology and Presentation

Hemorrhoids are vascular cushions in the lower rectum and anus. The role of hemorrhoids is not entirely clear, but it has been proposed that they contribute to sensation and continence. There are two types of hemorrhoids: internal and external. Internal hemorrhoids are inside the anal canal and are covered by anal mucosa. In most patients, one can identify three columns of hemorrhoids, two on the right and one on the left. However, several variations exist, and some patients have more than three bundles. External hemorrhoids occupy the inferior aspect of the anal canal and are covered by anoderm and skin. External hemorrhoids can be present in one or more quadrants or can be circumferential.

The exact cause of hemorrhoids is unknown. Several contributing factors have been implicated, including the upright posture of humans,

aging, pregnancy, heredity, constipation or chronic diarrhea, and spending excessive periods of time on the toilet (ie, reading, straining).

Patients often complain, "Doc, I have hemorrhoids," equating any anorectal symptoms with hemorrhoidal disease, including bleeding, lumps, masses, and pain. It is important to keep in mind that although hemorrhoids are common, the differential diagnoses for anorectal disorders include dermatologic

diseases such as pruritus ani, abscess and fistula, fissure, sexually transmitted diseases, warts, HIV, atypical infections such as tuberculosis, inflammatory ulcers such as Crohn's disease, and malignancy.

Although severe anal pain is often attributed to hemorrhoids, they are rarely the cause. In the absence of visible, thrombosed external hemorrhoids (blood clot and swelling), severe pain is frequently secondary to anal fissure,

not an internal hemorrhoid.

Evaluation and Management

The medical history should include the duration and nature of the symptoms, bowel habits, comorbid conditions, prior abdominal or anal surgeries, medications including nonsteroidal anti-inflammatory drugs (NSAIDS) and anticoagulants, prior endoscopic examination, and family history of gastrointestinal disorders.

The physical examination should include visual inspection of the anal region, digital examination, and anoscopy. Patients younger than age 50 years should undergo a flexible sigmoidoscopy, especially if bleeding is a presenting complaint. Colonoscopy is recommended for patients older than age 50 years, patients of any age with bleeding and anemia, those with persistent bleeding despite medical therapy, select patients with significant family history of colorectal malignancy, and patients with other symptoms such as abdominal pain and bloating and diarrhea.

Contrary to popular belief, not all hemorrhoids require treatment. Treatment should be reserved for symptomatic hemorrhoids only. It is important to reassure patients that hemorrhoids are part of normal anatomy and to dispel myths such as "if they are left alone, they will turn into cancer" or "hemorrhoids are blocking my anus." Treatment

is not based on hemorrhoid size or aesthetic appearance.

Possible causes of severe anal pain

Thrombosed external hemorrhoids

Anal fissure

Anal abscess

Acute herpetic ulceration or other sexually

transmitted diseases

Crohn's ulceration and inflammation

Anal, rectal, or pelvic cancer

Lymphoma or leukemia

When Should the Patient See a Surgeon?

Most of the time, hemorrhoidal disease will respond to conservative measures as long as the patient complies with the prescribed regimen. Surgical intervention for hemorrhoids is less frequently undertaken today than in the past.

Conclusion

Hemorrhoids are common, affecting millions of Americans. It is important to distinguish this disease from other anorectal diseases. Avoidance of constipation is key in treating hemorrhoids. Most patients can be effectively treated with fiber supplementation and local ointments. Surgical intervention is now less frequently undertaken than in the past but can be considered for patients with acute complications of hemorrhoidal disease or those in whom conservative treatment has failed.