CS Hemorrhoid

• Hemorrhoidal cushions (Corpus cavernosum recti)

• Three main hemorrhoidal complexes traverse the anal canal—the left lateral,
the right anterior, and the right posterior. (3, 7 and 11 o’clock when viewed in
the lithotomy position)
Hemorrhoid
 Classification
• Internal hemorrhoids originate from the superior
(internal) hemorrhoidal plexus immediately above
the dentate line and are covered with mucosa
and transitional zone epithelium and represent
majority of hemorrhoids.
• External hemorrhoids originate from inferior
(external) hemorrhoidal plexus below the dentate
line and are covered with squamous epithelium
and are associated with an internal component.
External hemorrhoids are painful when
thrombosed.

• Because of the communication (anastomoses)

between the internal and external hemorrhoidal
plexuses, which tend to increase with age, most
patients have both internal and external
hemorrhoids.
 Epidemiology
• affect >1 million individuals in the
Western world per year
• The prevalence rate is 4.4% in the US,
similar in both genders, with a peak
from 45 to 65 years
• less in underdeveloped countries (the
typical low-fiber, high-fat Western diet
is associated with constipation and
straining and the development of
symptomatic hemorrhoids)
RF
• Aging (elastic and connective
tissue may lose its abilities to
recoil)
• Conditions associated with
increased anal tone (chronic
straining on defecation,
constipation, diarrhea)
• Increased intra-abdominal
pressure such as pregnancy
• Portal hypertension
Patgen
• RF  weakening of the supporting tissues  slippage of the anal
cushions  prolapse  hinders the venous flow leading to dilatation
and engorgement of the anal cushions  exposing them to
complications such as edema, thrombosis, and bleeding
CM
• Small hemorrhoids cause virtually no problem. The most common
manifestation is bleeding, manifested as streaks of blood on the
outside of the stool / bright red blood seen either in the toilet or upon
wiping.
• When hemorrhoids become larger, they may prolapse and fail to return
following defecation, thereby drawing attention to themselves.
Prolapsed hemorrhoids may produce a mucoid discharge, but pain is
usually a feature only when they are acutely prolapsed, inflamed,
thrombosed, or infarcted.
• pruritus ani (anal itching) may accompany
• Occasionally patients can present with significant bleeding, which may
be a cause of anemia
• Often internal haemorrhoids are asymptomatic.
 Diagnosis
• HT  bleeding,
protrusion, pain, and
bowel habits
• Inspection of the
perianal region 
evidence of thrombosis
or excoriation
• Digital rectal
examination
• Anoscopy 
visualization & position
of internal hemorrhoidal
Staging & Treatment
Prognosis
• The majority of the hemorrhoidal symptoms permanently abate after
adequate therapy with or without surgery.
• Untreated hemorrhoids may rarely lead to anemia, thrombosis, or
incarceration
DDx
• Hemorrhoidal bleeding needs to be differentiated from neoplasia,
polyps, inflammatory bowel disease, anal fissure, abscess, fistula,
and prolapse.
• It is rarely dark, melenic, or mixed with stool.
• Patients older than 40 years or with atypical symptoms should
undergo complete colonic investigation to exclude cancer.
• Inflammatory bowel disease is marked by bloody diarrhea.
• If pain is present, anal fissure and abscess must be considered.
• Prolapsing hemorrhoids may be confused with rectal prolapse,
polyps, hypertrophied papillae, or skin tags.