Symptomatic Hemorrhoids Susan L Gearhart, MD Assistant Professor of Surgery, Colorectal Surgery, Johns Hopkins Medicallnstitutions, Lutherville, Maryland

CHAPTER 9 Symptomatic Hemorrhoids Susan L Gearhart, MD Assistant Professor of Surgery, Colorectal Surgery, Johns Hopkins Medicallnstitutions, Lutherville, Maryland 1though the true incidence of symptomatic hemorrhoids is Adifficu1t to estimate, the significance and management of this disorder has been well documented. The earliest writings on the subject of symptomatic hemorrhoids occurred in 400 BCby Hip- pocrates.1 In these writings, symptomatic hemorrhoids were de- scribed as the resu1t of infection of the veins within the rectum with stool, causing the temperature within the vein to rise and the vein to swell. Successful treatment could be obtained by cauterizing the hemorrhoids with a red-hot iron. Napo1eon was finally defeated by the British at the Battle of Waterloo in 1815. Severa1 accounts by those who were dose to him have indicated that the battle was 10st because ofNapoleons aftliction with hemorrhoids.2 Contrary to his usual batt1e conduct, he spent most of his time resting on a hilltop overlooking the battlefield rather than on his horse. When he did wa1k, he had a difficu1t time. Furthermore, a 1etter to his brother written severa1 years before the Battle of Waterloo indicated he had been routine1y treating his hemorrhoids with 3 to 4 1eeches. Today, if one browses the Internet on the topic of hemorrhoids, there are more than 65,000 sites that can be visited. ANATOMYANDPATHOPHYSIOLOGY Figure 1 demonstrates the anatomic abnormalities associated with the development of symptomatic hemorrhoids. Hemorrhoidal cushions are essential to the function ofthe anal canal. The hypervascu- lar nature of these cushions allows control of fecal continence and the easy passage of formed stool. In contrast with the submucosa of the proximal gastrointestinal tract, the submucosa of the anal canal is not a continuous rim, but a discontinuous series ofvascu1ar cushions. 3,4These hemorrhoidal cushions are found in the right anterior, Advances in Surgery@, vol 38 167 Copyright 20M, Mosby, Inc. Ali rights reserved. 44 ''''''--'~' '. 168 S.L.Gearhart Superior rectaJ a.andv. Mlddle hemorrholdaJ a.andv. Inferior hemorrhoidal a.andv. \ FIGURE1. Cross-sectional view of nonprolapsing and prolapsing hemorrhoid com- plexes. right posterior, and left lateral position. These cushions are sup- ported by a connective tissue framework derived from the internal anal sphincter and longitudinal muscle within the anal canal. The blood supply to the anal canal. which terminates in the anal cushions, stems from the superior rectal artery from the inferior mesen- teric artery and the middle and inferior rectal arteries from the internal iliac artery. Above the dentate line within the anal canal, the venous drainage follows the portal system into the inferior mesen- teric vein. In contrast, below the dentate line. the venous plexus drains into the systemic system. In the process of elimination of stool, anal cushions serve 2 purposes: 1) the control of fine continence and 2) the evacuation of 45 Symptomatic Hemorrhoids 169 formed stool through a muscular tube without injury to the mucosal lining. The distention of the rectum with waste results in engorgement of the vascular cushions of the anal canal. Within the mucosa overlying the anal cushions are sensory receptors that are essential to fine adjustments in continence.5.6 These receptors function. for example, to promote the elimination of gaseous waste in preference to liquid or solid waste. The engorgement of the vascular cushions allows solid waste to be evacuated completely and without injury to the anal canal. Although severa! theories exist regarding the pathogenesis of symptomatic hemorrhoids, it is generaIly believed that this disorder arises from a history of straining with defecation and as part of the aging process.7-9It is believed that the supportive connective tissue gives way with constant straining resulting in prolapse of the hemorrhoid cushion. Once the hemorrhoid complex begins to prolapse. venous return is impaired. resulting in engorgement, irritation, and inflammation. Erosion of the inflamed epithelium results in bleeding. Congenital internal anal sphincter hypertension has also been implicated in the pathogenesis ofhemorrhoidal disease.9.10 CLASSIFICATION As in most disease states, classification is considered useful for the management of symptomatic hemorrhoids. Hemorrhoids historically have been classified based on their location and the degree of prolapse.ll The dentate line demarcates the upper anal canal, lined with columnar epithelium. from the lower ana! canal, which is lined with sensate squamous epithelium. Internal hemorrhoids, in the most common location ofhemorrhoids, occur above the dentate line. External hemorrhoids are found below the dentate line (see Fig 1). Internal hemorrhoids are further classified by the degree of prolapse. · First-degree hemorrhoids do not prolapse with straining. but can be associated with bleeding. ·Second degree hemorrhoids protrude below the dentate line dur- ing straining but wiIl spontaneously retract. · Third degree hemorrhoids protrude outside the anal canal with straining and require manual reduction. ·Fourth degree hemorrhoids remain prolapsed independent of straining and are irreducible. 46 170 S. L. Gearhart PRESENTATlONAND DIAGNOSIS Bleeding is the symptom most commonly associated with hemorrhoids. The bleeding is bright red, noted on wiping or filling the toilet bowl, and occurring predictably with defecation. Prompt reduction of the prolapsed hemorrhoid will significantly reduce the bleeding. Patients with third- or fourth-degree hemorrhoids com- plain of protruding, irritated tissue in the perianal region. Third- and fourth-degree hemorrhoids may aIso cause a feeling of incom- plete evacuation. The prolapsed tissue gives a sense of fullness and a continuing sense of the need to evacuate. Soiling in the form of mucus discharge is not uncommon, because of an impairment ofthe fine control of continence. Constant exposure of the perianal skin to mucus may result in irritation and itching. Discomfort may be associated with prolapsed hemorrhoids; however, intolerable pain is rare. A painful hemorrhoid is usually an acutely thrombosed, prolapsed internal or external hemorrhoid. Pain is associated with a perianal mass, which is immediately evident on physical examination. The diagnosis ofhemorrhoidal disease is usually made with pal- pation and direct visualization ofthe perianal region and anal canal through anoscopy. Prolapsing or thrombosed hemorrhoids are evident on inspection of the perianal tissue. These findings can be ex- aggerated with straining. Thrombosed hemorrhoids have a blue hue as a result of the clotted blood inside. On anoscopy, inflamed hemorrhoids may be visualized in their previously mentioned anatomi- cal position. Individuals seeking medical attention for perianal discomfort often report that they have hemorrhoids. Unfortunately, this is due to the lack ofpatient and physician education. Most perianal condi- tions are incorrectly labeled as "hemorrhoids." Anal fissures arise in the sensate portion of the anal canal and are associated with excru- ciating pain more so than bleeding. It is true that because the patho is similar to that of hemorrhoids, it is not uncommon for the two to exist together. Mucosal prolapse, a circumferential prolapse of the anal canal mucosa, is a common condition of older women. The symptoms resulting from mucosal prolapse as well as the medical management are similar to hemorrhoidal disease. Most importantly, a more serious condition often mistaken for hemorrhoids is anal or rectal cancer. Any examination of patients with hematochezia should include suf:ficient investigations to rule out a proximal source of bleeding if the bleeding does not cease afier appropriate 47 Symptomatic Hemorrhoids 171 therapy. Furthermore, hemorrhoidal bleeding rarely causes iron- deficiency anemia.12 Other disorders, such as intlammatory bowel disease or cancer, should be ruled out. TREATMENT DIETARYAND UFESTYLEALTERATlONS It has been shown that fiber supplementation reduces the bleeding and discomfort associated with hemorrhoids.13 However, fiber supplementation will not reduce the prolapse. It may be weeks before the use of fiber for the treatment of symptomatic hemorrhoids is ef- fective. It is recommended that patients take 30 gm of fiber a day and increase liquid intake. This goal is difficult to reach without the as- sistance of fiber supplementation. Fiber therapy should be insti- tuted gradually over the course of a week. This will reduce the incidence of unwanted side effects of bloating. Supplemental semi- synthetic tlavonoids are commonly prescribed in Europe and Asia for the treatment of hemorrhoids. This remedy willlikely improve venous tone and inhibit the release ofprostaglandins, thus resulting in symptomatic relief.14 Patients should be counseled on specific activity related to defecation. Avoiding straining is essential. The bathroom is to be used for the sole purposes of evacuation of waste and not for reading. Pa- tients should be instructed to remain on the toilet seat for no longer than 1 minute. Furthermore, attempts at defecation should be made only afier the patient receives a clear call to eliminate waste. MEDICALMANAGEMENT Historically, symptomatic relief from acutely intlamed hemorrhoids was bed rest and ice packs. Acute surgical therapy was deemed un- safe because of the risk of internal sphincter injury. However, with improvement

Load more