Hemorrhoids - A Complete Review

Introduction:

Normal symptomatic anal expansion and distal displacement are known as hemorrhoids. Hemorrhoid's most typical symptom is rectal bleeding during bowel movements. Unusual deformation and dilating of the hemorrhoids are primarily identified by a vascular channel and adverse changes in the connective tissue that supports the anal cushion. A potential focus for medical treatment is the dysregulation of vascular tone and vascular hyperplasia, which may be crucial in developing hemorrhoids.

What Are Hemorrhoids?

Hemorrhoids, characterized by the symptomatic expansion and distal displacement of the typical anal cushions, are a relatively prevalent anorectal disease. Consequently, they are a significant medical and economic issue affecting millions worldwide. Several conditions, including constipation and extended straining, have allegedly caused hemorrhoidal development. A key indicator of hemorrhoidal illness is aberrant vascular channel dilatation and distortion, together with degenerative alterations in the connective tissue that supports the anal cushion. In addition, hemorrhoids may show vascular hyperplasia (excessive cell increase) and inflammatory response.

How Are Hemorrhoids Classified?

For practical purposes, internal hemorrhoids are categorized using Goligher's categorization according to their appearance and degree of prolapse:

• Grade I - First-degree hemorrhoids. Anal cushions are bloody, but avoid prolapsing.

• Grade II - Second-degree hemorrhoids. When strained, the anal cushions prolapse through the anus but spontaneously disappear.

• Grade III - Third-degree hemorrhoids. When exerting or straining, the anal cushions prolapse through the anus and must be manually replaced into the anal canal.

• Grade IV - Fourth-degree hemorrhoids. The prolapse is irreducible and always present. Fourth-degree hemorrhoids include acutely thrombosed, imprisoned internal, and incarcerated, thrombosed hemorrhoids, including circumferential rectal mucosal prolapse.

What Is the Cause of Hemorrhoids?

Hemorrhoids are frequently attributed to constipation and prolonged straining because hard stool and increased intraabdominal pressure may impede venous return and produce engorgement of the hemorrhoidal plexus. In addition, the shearing force on the anal cushions rises with hard fecal material defecation. Recent research, however, calls into doubt the role that constipation plays in the emergence of this widespread ailment. While some publications suggested that diarrhea is a risk factor for developing hemorrhoids, many researchers have been unable to show any substantial link between hemorrhoids and constipation. In patients with a history of hemorrhoidal disease, an increase in defecation strain may hasten the onset of symptoms, including bleeding and prolapse.

What Is the Pathophysiology of Hemorrhoids?

Hemorrhoids form when the anal cushion's supporting tissues break down or degrade. Therefore, hemorrhoids are the pathological name for the aberrant downward displacement of the anal cushions, resulting in venous dilatation. Right anterior, right posterior, and left lateral areas of the anal canal typically contain three primary anal cushions, with varying numbers of lesser cushions positioned in between. Hemorrhoid sufferers' anal cushions have severe pathological alterations. These alterations include the following:

• Arterial thrombosis (blood clot in the arteries).

• Aberrant venous dilatation (sudden dilations of the veins).

• A degenerative process in the collagen fibers and fibroelastic tissues.

• Distortion and rupture of the anal subepithelial muscle.

How Are Hemorrhoids Diagnosed?

• Painless Rectal Bleeding - The most typical symptom of hemorrhoids is painless rectal bleeding connected to bowel movements, which patients describe as blood dripping into the toilet bowl. Because hemorrhoidal tissue has a direct arteriovenous connection, the blood is often bright red. Hemorrhoids should not be blamed for positive fecal occult blood or anemia until the colon has been thoroughly examined, especially if the bleeding is unusual for hemorrhoids, if there is no sign of a source of bleeding on an anorectal examination, or if the patient has significant risk factors for colorectal neoplasia. Due to mucous production or fecal soiling, prolapsing hemorrhoids can produce perineal irritation or anal itching.

• Incomplete Evacuation - A sense of incomplete evacuation or rectal fullness is also noted in individuals with big hemorrhoids. Hemorrhoids rarely produce pain unless thrombosis has developed, especially in external hemorrhoids or if a fourth-degree internal hemorrhoid strangulates. The more typical causes of anal pain in hemorrhoidal patients include anal fissures and perianal abscesses. Anal skin tags, external hemorrhoids, perianal dermatitis from anal discharge or fecal soiling, fistula-in-ano, and anal fissure should all be looked for in the perianal region. A digital examination can detect abnormal anorectal masses, anal stenosis, and scars, assess anal sphincter tone, and determine prostatic hypertrophy status, which may cause straining as this worsens the descent of the anal cushions during micturition even though internal hemorrhoids cannot be palpated.

• Anoscopy - The size, position, degree of bleeding, and hemorrhoidal irritation should all be documented during anoscopy. In addition to allowing for the excellent sight of the anal canal and hemorrhage, intrarectal retroflection of the colonoscope or transparent anoscope with a flexible endoscope also allows for picture recording.

How Are Hemorrhoids Managed?

Hemorrhoids are typically treated conservatively with various techniques, including dietary changes, fiber supplements, suppository-delivered anti-inflammatory medications, and the administration of vagotonic medicines. Sclerotherapy and, preferably, rubber band ligation are non-operative methods. Surgery is indicated when non-operative methods have failed, or complications have occurred. Hemorrhoidectomy and stapled hemorrhoidopexy are two surgical methods for treating hemorrhoids. However, postoperative discomfort is always present. In addition, some surgical procedures, such as anal stricture and incontinence, have a significant risk of causing morbidity.

What Is Hemorrhoidectomy?

Excisional hemorrhoidectomy has the lowest recurrence rate compared to other modalities and is the most effective treatment for hemorrhoids. Scissors, diathermy, or vascular-sealing tools like ligasure and harmonic scalpel might be used for the procedure. Excisional hemorrhoidectomy can be carried out successfully as an outpatient procedure with perianal anesthetic infiltration. The indications for hemorrhoidectomy are as follows:

• Acute complicated hemorrhoids with strangulation or thrombosis.

• Patient preference.

• Anal fistula.

• Third- or fourth-degree internal hemorrhoids.

Conclusion:

Depending on the extent and severity of symptoms, treatment options for hemorrhoids can range from dietary and lifestyle changes to major surgery. Although surgery is an effective treatment for hemorrhoids, it should only be used in cases of advanced disease because it can lead to significant side effects. Non-operative treatments are not entirely effective, particularly those that take a topical or pharmacological approach. Therefore, improvements in the understanding of the pathophysiology of hemorrhoids are required to encourage the development of new and creative treatments for hemorrhoids.