Hemorrhoids

Introduction to Hemorrhoids

According to Love and Bailey’s “A Short Practice of Surgery”, hemorrhoids are vascular cushions located in the anal canal that consist of blood vessels, smooth muscle, and connective tissue. When these cushions become engorged, prolapsed, or symptomatic, they are referred to as hemorrhoidal disease.

Historical Perspective

Term derived from Greek “haima” (blood) and “rhoos” (flowing)
One of the oldest recorded medical conditions - mentioned in Egyptian papyri (1700 BC)
Hippocrates described treatment with cautery
Common condition affecting millions worldwide

Epidemiology

Population	Prevalence	Remarks
General Population	4-5%	Higher in Western countries
Age >50 years	50%	Peak incidence 45-65 years
Gender Distribution	Equal M:F	Slightly more common in males
Pregnant Women	25-35%	Usually resolves postpartum

Surgical Anatomy of Hemorrhoids

Anatomy of Anal Canal

Structure	Length	Features
Anal Canal	4 cm (adults)	Extends from anorectal junction to anal verge
Dentate Line	Mid-anal canal	Embryological junction between endoderm and ectoderm
Anal Columns (Columns of Morgagni)	6-10 vertical folds	Contain terminal branches of superior rectal artery
Anal Valves	At bases of columns	Semilunar folds between columns
Anal Crypts	Above valves	Openings of anal glands

Hemorrhoidal Vascular Cushions

Cushion	Position	Arterial Supply	Clinical Significance
Left Lateral	3 o’clock (lithotomy)	Inferior mesenteric → superior rectal artery	Most common site for bleeding
Right Anterior	11 o’clock (lithotomy)	Internal iliac → middle rectal artery	Common in pregnant women
Right Posterior	7 o’clock (lithotomy)	Internal iliac → middle rectal artery	Often associated with prolapse

Blood Supply

Artery	Origin	Distribution
Superior Rectal Artery	Inferior mesenteric artery	Main supply to internal hemorrhoids
Middle Rectal Artery	Internal iliac artery	Anastomoses with superior and inferior rectal arteries
Inferior Rectal Artery	Internal pudendal artery	Supplies external hemorrhoids and sphincters

Venous Drainage

Above dentate line: Superior rectal vein → inferior mesenteric vein → portal system
Below dentate line: Inferior rectal vein → internal pudendal vein → internal iliac vein → systemic system
Clinical significance: Portal hypertension can cause hemorrhoids but is not the primary cause

Nerve Supply

Area	Innervation	Sensation
Above Dentate Line	Autonomic nerves (sympathetic and parasympathetic)	Visceral pain (dull, poorly localized)
Below Dentate Line	Inferior rectal nerves (somatic)	Somatic pain (sharp, well-localized)

Classification of Hemorrhoids

Anatomical Classification

Type	Location	Covering	Nerve Supply
Internal Hemorrhoids	Above dentate line	Columnar epithelium	Autonomic (pain insensitive)
External Hemorrhoids	Below dentate line	Stratified squamous epithelium	Somatic (pain sensitive)
Mixed Hemorrhoids	Above and below dentate line	Both epithelial types	Both autonomic and somatic

Goligher’s Classification of Internal Hemorrhoids

Grade	Description	Clinical Features	Treatment Options
First Degree	Bleed but do not prolapse	Bright red bleeding, no prolapse	Diet, fiber, sclerotherapy, banding
Second Degree	Prolapse on straining but reduce spontaneously	Prolapse with defecation, spontaneous reduction	Banding, infrared coagulation, hemorrhoidectomy
Third Degree	Prolapse and require manual reduction	Prolapse requires manual reduction	Hemorrhoidectomy, stapled hemorrhoidopexy
Fourth Degree	Permanently prolapsed and irreducible	Chronic prolapse, may strangulate	Emergency hemorrhoidectomy if strangulated

External Hemorrhoid Types

Type	Features	Management
Cutaneous Tags	Skin folds, usually asymptomatic	Reassurance, excision if symptomatic
Thrombosed External Hemorrhoid	Acute painful swelling due to thrombosis	Evacuation if <72 hours, conservative if >72 hours
Chronic External Hemorrhoid	Persistent swelling, irritation	Excision if symptomatic

Etiology and Pathophysiology

Pathophysiological Theories

Theory	Proponent	Mechanism	Evidence
Varicose Vein Theory	Ancient theory	Dilatation of hemorrhoidal veins	Weak evidence - hemorrhoids are vascular cushions, not varicosities
Sliding Anal Lining Theory	Parks (1956)	Weakening of supporting tissues leads to prolapse	Currently accepted theory
Vascular Hyperplasia Theory	Thomson (1975)	Engorgement of vascular cushions	Hemorrhoids contain arteriovenous communications

Risk Factors

Risk Factor	Mechanism	Strength of Association
Chronic Constipation	Increased straining, raised intra-abdominal pressure	Strong
Pregnancy	Mechanical pressure, hormonal changes	Strong
Aging	Weakening of connective tissue supports	Strong
Prolonged Sitting	Increased venous pressure in pelvis	Moderate
Heavy Lifting	Increased intra-abdominal pressure	Moderate
Obesity	Increased intra-abdominal pressure	Moderate
Low Fiber Diet	Leads to constipation and straining	Strong
Family History	Genetic predisposition	Weak to moderate
Portal Hypertension	Increased venous pressure	Weak (not primary cause)

Pathological Changes

Degeneration of supporting tissues: Treitz’s muscle and connective tissue
Vascular changes: Dilatation of venules, arteriolar hypertrophy
Inflammation: Secondary to trauma, thrombosis, or infection
Fibrosis: Chronic inflammation leads to fibrosis
Thrombosis: Particularly in external hemorrhoids

Clinical Features

Symptoms of Hemorrhoids

Symptom	Internal Hemorrhoids	External Hemorrhoids	Clinical Significance
Bleeding	Common (bright red, on toilet paper or dripping)	Rare (only if ulcerated)	Most common presenting symptom
Prolapse	Grades II-IV	Not applicable	Indicates more advanced disease
Pain	Rare (unless thrombosed or strangulated)	Common (especially when thrombosed)	Pain suggests complication or alternative diagnosis
Pruritus	Common (due to mucus secretion)	Less common	Due to moisture and irritation
Soiling	Common (incomplete closure of anal canal)	Less common	Due to prolapse interfering with closure

Special Clinical Scenarios

Thrombosed External Hemorrhoid

Presentation: Acute, severe perianal pain with sudden onset
Examination: Tender, bluish, swollen lump at anal verge
Natural history: Pain peaks at 48 hours, resolves in 7-10 days
Treatment: Evacuation if <72 hours, conservative if >72 hours

Strangulated Hemorrhoids

Pathophysiology: Prolapsed hemorrhoids with compromised blood supply
Clinical features: Severe pain, swelling, tenderness, possible necrosis
Treatment: Emergency hemorrhoidectomy
Complications: Gangrene, sepsis, portal pyaemia (rare)

Hemorrhoids in Pregnancy

Incidence: 25-35% of pregnancies
Causes: Mechanical pressure, hormonal changes, constipation
Management: Conservative (fiber, stool softeners, topical treatments)
Surgery: Reserved for severe complications

Diagnosis of Hemorrhoids

Clinical Assessment

Examination	Technique	Findings
Inspection	Patient in left lateral position, examine perianal area	External hemorrhoids, skin tags, prolapse, excoriation
Digital Rectal Examination	Lubricated gloved finger, assess tone, masses, tenderness	Internal hemorrhoids usually not palpable unless thrombosed
Proctoscopy	Patient straining, proctoscope inserted and slowly withdrawn	Internal hemorrhoids bulge into lumen at 3,7,11 o’clock
Sigmoidoscopy/Colonoscopy	If bleeding or age >50 years, to exclude other pathology	Rule out colorectal cancer, inflammatory bowel disease

Differential Diagnosis

Condition	Distinguishing Features
Anal Fissure	Sharp pain with defecation, sentinel pile, visible fissure
Perianal Abscess/Fistula	Pain, swelling, discharge, fever, external opening
Rectal Prolapse	Concentric mucosal folds, complete thickness prolapse
Anal Cancer	Ulcerated, indurated lesion, bleeding, pain
Condylomata Acuminata	Wart-like lesions, multiple, may be extensive
Inflammatory Bowel Disease	Diarrhea, mucus, systemic symptoms, perianal skin tags
Rectal Polyp/Cancer	Altered bowel habit, weight loss, anemia, mass on examination

Investigations

Investigation	Indications	Findings
Complete Blood Count	Significant bleeding, anemia suspected	Anemia (microcytic if chronic bleeding)
Coagulation Profile	Bleeding diathesis suspected	Prolonged PT/PTT if coagulopathy
Flexible Sigmoidoscopy	Age <50 years with bleeding, no alarm features	Exclude distal colorectal pathology
Colonoscopy	Age >50 years, family history, alarm features	Exclude colorectal cancer, polyps, IBD
Anorectal Physiology	Incontinence, prior anal surgery	Assess sphincter function

Treatment of Hemorrhoids

Conservative Management

Modality	Mechanism	Indications	Effectiveness
Dietary Modification	Increase fiber, fluids to soften stools	All grades, first-line treatment	50% reduction in symptoms
Topical Treatments	Local anesthesia, anti-inflammatory, vasoconstriction	Symptomatic relief	Good for symptom control
Sitz Baths	Warm water improves hygiene, reduces sphincter spasm	Pain, irritation, postoperatively	Good symptomatic relief
Stool Softeners	Reduce straining	Constipation, postoperative	Effective for constipation

Office-Based Procedures

Procedure	Mechanism	Indications	Success Rate	Complications
Rubber Band Ligation	Ischemic necrosis of hemorrhoid	Grade I-III hemorrhoids	70-80%	Pain, bleeding, thrombosis
Sclerotherapy	Fibrosis and fixation of mucosa	Grade I-II hemorrhoids	60-70%	Ulceration, prostatitis, impotence (rare)
Infrared Coagulation	Coagulation and fibrosis	Grade I-II hemorrhoids	60-70%	Mild pain, bleeding
Cryotherapy	Tissue destruction by freezing	Historical, rarely used now	Variable	Profuse discharge, pain

Surgical Procedures

Procedure	Technique	Indications	Advantages	Disadvantages
Milligan-Morgan (Open) Hemorrhoidectomy	Excision of hemorrhoids with ligation of pedicle	Grade III-IV, failed conservative treatment	Definitive, low recurrence	Painful, longer recovery
Ferguson (Closed) Hemorrhoidectomy	Excision with primary closure	Grade III-IV hemorrhoids	Less pain, faster healing	Technical difficulty, hematoma risk
Stapled Hemorrhoidopexy (PPH)	Circular stapler to resect mucosa and reposition hemorrhoids	Grade III-IV circumferential hemorrhoids	Less pain, faster recovery	Cost, rare serious complications
Doppler-guided Hemorrhoidal Artery Ligation (HAL)	Ligation of hemorrhoidal arteries under Doppler guidance	Grade II-III hemorrhoids	Minimal pain, minimal tissue damage	Special equipment, higher recurrence

Treatment Algorithm According to Love & Bailey

Grade	First-line	Second-line	Third-line
I	Diet, lifestyle, topical treatments	Banding, sclerotherapy	Infrared coagulation
II	Diet, lifestyle, banding	Sclerotherapy, infrared coagulation	Hemorrhoidectomy if persistent
III	Banding, hemorrhoidectomy	Stapled hemorrhoidopexy	HAL-RAR
IV	Hemorrhoidectomy	Stapled hemorrhoidopexy	Combined procedures

Complications of Hemorrhoids and Their Treatment

Complications of Hemorrhoidal Disease

Complication	Incidence	Management
Anemia	0.5-1% of patients	Iron supplementation, definitive treatment of hemorrhoids
Strangulation	2-3% of prolapsed hemorrhoids	Emergency hemorrhoidectomy
Thrombosis	5-10% of external hemorrhoids	Evacuation if early, conservative if late
Gangrene	Rare	Emergency surgery, antibiotics
Fibrosis/Stenosis	Chronic cases	Dilatation, surgery

Complications of Surgical Treatment

Complication	Incidence	Prevention	Management
Pain	Common (especially open hemorrhoidectomy)	Multimodal analgesia, topical treatments	Analgesics, sitz baths
Bleeding	1-2% (primary), 0.5-1% (secondary)	Meticulous technique, secure pedicle ligation	Pressure, suture ligation, packing
Urinary Retention	10-15%	Adequate hydration, limited IV fluids, pain control	Catheterization if persistent
Infection	0.5-1%	Aseptic technique, perioperative antibiotics if indicated	Antibiotics, drainage if abscess
Anal Stenosis	1-2%	Preserve mucosal bridges, avoid excessive excision	Dilatation, anoplasty
Incontinence	Rare (0.5%)	Careful surgical technique, preserve sphincters	Biofeedback, surgical repair if severe

Special Considerations

Hemorrhoids in Immunocompromised Patients

Avoid invasive procedures if possible
Higher risk of infection and poor healing
Conservative management preferred
If surgery needed, meticulous technique and antibiotic prophylaxis

Hemorrhoids in Inflammatory Bowel Disease

Conservative management preferred
Surgery only for severe symptoms
Risk of poor healing and fistula formation
Coordinate care with gastroenterologist

Recurrent Hemorrhoids

Evaluate for underlying causes (chronic constipation, etc.)
Consider alternative procedures
May require re-do hemorrhoidectomy
Assess sphincter function preoperatively

References

Love, R. J. M., & Bailey, H. (Latest Edition). A Short Practice of Surgery. London: Edward Arnold.
Chapter on Anorectal Diseases in Love & Bailey’s textbook
American Society of Colon and Rectal Surgeons Clinical Practice Guidelines
Association of Coloproctology of Great Britain and Ireland Guidelines
World Society of Emergency Surgery Guidelines

Key Learning Points from Love & Bailey

“Hemorrhoids are a common condition that can usually be managed conservatively. Surgical intervention should be reserved for cases that fail conservative measures or present with complications. A thorough understanding of anal anatomy is essential for safe and effective treatment.”
- Love & Bailey, A Short Practice of Surgery

Important Clinical Pearls

Never attribute rectal bleeding to hemorrhoids without proper examination
Pain is not a typical feature of uncomplicated internal hemorrhoids
Conservative management should always be tried first
Always consider and exclude other causes of rectal bleeding
Patient education about bowel habits is crucial for prevention
Surgical treatment should be tailored to the grade of hemorrhoids and patient factors
Postoperative pain management is essential for patient satisfaction

This educational blog is based on the surgical textbook “A Short Practice of Surgery” by Love and Bailey.

For medical professionals and students only. Always consult current guidelines and local protocols.