II. Definition
- Dilation of anorectal vessels
III. Epidemiology
- Most common Anorectal Condition
- Affects 50% of patients over age 50 years
IV. Anatomy
- See Rectal Anatomy
-
Dentate Line
- At midpoint of roughly 4 cm long anus
- Proximal to Dentate Line
- Lined by columnar epithelium
- Shares visceral innervation and typically painless
- Internal Hemorrhoids form in this region
- Distal to Dentate Line
- Lined by squamous epithelium
- Somatic innervation and painful
- External Hemorrhoids form in this region
- Positions for internal and External Hemorrhoids
- Right Anterior
- Right Posterior
- Left Lateral
V. Pathophysiology
- Anal venous plexus of submucosal vessels dilate
- Results in a focal swelling of rectal mucosa
- Connective tissue supporting vessels weakens and allows Hemorrhoid descent and prolapse
VI. Types
-
Internal Hemorrhoids
- Above Dentate Line, share visceral innervation and are painless
-
External Hemorrhoids
- Below Dentate Line, and are potentially painful
VII. Causes: Increase pressure in anal venous plexus
- Prolonged erect Posture
- Back flow
- Abdominal pressure
- Constipation and straining at Defecation
- Pregnancy
- Expect resolution after delivery
- Surgical intervention is both contraindicated and unnecessary
- Diarrhea (Relative Risk 2.1)
- Obesity (Relative Risk 1.7)
- Family History
- Portal Hypertension (Cirrhosis) and Ascites
- Pelvic Floor Dysfunction
- Low fiber diet
- Anatomic abnormalities
- No Hemorrhoidal venous valves
- Intrinsic weakness of anal blood vessels
VIII. Symptoms (asymptomatic in >50% of patients)
- Pruritus Ani
- Rectal Bleeding (often with streaks of blood on surface of stool)
- Rectal Pain (External Hemorrhoid, Thrombosed Hemorrhoid)
- Prolapsed Hemorrhoid (with risk of soiling)
- Fullness or mass Sensation
IX. Signs
- Visual inspection
- Digital Rectal Exam
-
Anoscopy (Ives Slotted Anoscope)
- Required to diagnose Internal Hemorrhoids (not discernable by Digital Rectal Exam)
- Internal Hemorrhoids will appear as dilated purple veins
X. Exam
- External anal exam
- Observe for external hemorroids (esp. Thrombosed Hemorrhoids)
- Prolapsed internal hemorroids
-
Digital Rectal Exam
- Rectal masses
- Focal tenderness or fullness
- Gross or Occult blood
-
Anoscopy
- See Anoscopy
XI. Differential Diagnosis
- Anal Fissure
- Perirectal Abscess
- Rectal Fistula to Perianal Abscess
- Anal Condyloma
- Anal Cancer or Colorectal Cancer
- Inflammatory Bowel Disease
- Perianal Skin Tags (remanants of prior External Hemorrhoids)
XII. Diagnostics: Colonoscopy indications
- See Colorectal Cancer Screening for guidelines irrespective of Hemorrhoids
- Suspected Inflammatory Bowel Disease
- Consider in age over 40 years and signs of Rectal Bleeding
- Other red flag symptoms with Rectal Bleeding
- Abdominal Pain
- Weight loss
- Fever
- Rectal Bleeding refractory to medical management
XIII. Precautions
-
Exercise caution in diagnosing Hemorrhoids as the cause of Rectal Bleeding
- Consider proximal causes of Rectal Bleeding (e.g. Colorectal Cancer, Inflammatory Bowel Disease)
- Anemia suggests other bleeding source, as Hemorrhoids rarely bleed enough to cause significant Anemia
XIV. Management
- See Hemorrhoid Management
- See Internal Hemorrhoid
- See External Hemorrhoid
- See External Thrombosed Hemorrhoid
XV. References
- Pickard in Dornbrand (1992) Ambulatory Care, p. 225-6
- Schrock in Feldman (1998) Sleisenger GI, p. 1964-7
- Hulme-Moir (2001) Gastroenterol Clin North Am 30:183-97 [PubMed]
- Hussain (1999) Prim Care 26(1):35-51 [PubMed]
- Mott (2018) Am Fam Physician 97(3): 172-9 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
| Definition (MEDLINEPLUS) |
Hemorrhoids are swollen, inflamed veins around the anus or lower rectum. They are either inside the anus or under the skin around the anus. They often result from straining to have a bowel movement. Other factors include pregnancy, aging and chronic constipation or diarrhea. Hemorrhoids are very common in both men and women. About half of all people have hemorrhoids by age 50. The most common symptom of hemorrhoids inside the anus is bright red blood covering the stool, on toilet paper or in the toilet bowl. Symptoms usually go away within a few days. If you have rectal bleeding you should see a doctor. You need to make sure bleeding is not from a more serious condition such as colorectal or anal cancer. Treatment may include warm baths and a cream or other medicine. If you have large hemorrhoids, you may need surgery and other treatments. NIH: National Institute of Diabetes and Digestive and Kidney Diseases |
| Definition (MSHCZE) | Hemoroidy – řitní žilní městky, „zlatá žíla“. Rozšíření žilních struktur, které jsou v okolí dolní části konečníku a řitního kanálu. Na jejich vzniku se podílejí značnou měrou poruchy vyprazdňování, zejm. dlouhodobá zácpa. Vnitřní h. se projevují krvácením a v pozdější době mohou vyhřezávat do řitního kanálu. V léčbě je důležitá péče o stolici, úprava stravy, místní léčba (koupele, masti, čípky), někdy lze použít sklerotizace (njekčního podání látky, která vede k jejich uzávěru a zjizvení), v těžších případech se operují. Zevní h., které jsou viditelné pouhým okem, mohou někdy způsobit velmi bolestivý zánět. (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ ) |
| Definition (NCI_CTCAE) | A disorder characterized by the presence of dilated veins in the rectum and surrounding area. |
| Definition (NCI) | Dilated veins in the anal canal.(NICHD) |
| Definition (NCI_NCI-GLOSS) | An enlarged or swollen blood vessel, usually located near the anus or the rectum. |
| Definition (MSH) | Swollen veins in the lower part of the RECTUM or ANUS. Hemorrhoids can be inside the anus (internal), under the skin around the anus (external), or protruding from inside to outside of the anus. People with hemorrhoids may or may not exhibit symptoms which include bleeding, itching, and pain. |
| Concepts | Acquired Abnormality (T020) |
| MSH | D006484 |
| ICD9 | 455 |
| ICD10 | I84 , K64 |
| SnomedCT | 155477004, 195472000, 155469003, 70153002 |
| HL7 | HEM |
| LNC | LP30519-0, MTHU015043 |
| English | HAEMORRHOIDS, HEMORRHOIDS, Haemorrhoids NOS, Hemorrhoids, hemorrhoids (diagnosis), hemorrhoids, Hemorrhoids [Disease/Finding], hemorrhoid (pile), haemorrhoid, pile, Hemorrhoids NOS (disorder), Haemorrhoid (disorder), Haemorrhoids NOS (disorder), hemorrhoid, Piles, Hemorrhoid, Haemorrhoid, Haemorrhoids, Piles - haemorrhoids, Piles - hemorrhoids, Hemorrhoids (disorder), Haemorrhoids, NOS, Hemorrhoids, NOS, Piles, NOS, Hemorrhoids NOS, piles, haemorrhoids |
| Portuguese | HEMORROIDAS, Hemorroidas, Hemorróidas |
| Spanish | HEMORROIDES, Almorranas, hemorroides, SAI (trastorno), Hemorrhoids NOS, Haemorrhoids NOS, hemorroides, SAI, hemorroides (trastorno), hemorroides, Hemorroides |
| German | HAEMORRHOIDEN, Haemorrhoiden, Hämorrhoiden |
| Dutch | aambeien, Hemorroàden, hemorroïden, Hemorroïden, Aambei, Aambeien, Hemorroïd |
| Japanese | 痔核, ｼﾞｶｸ |
| Swedish | Hemorrojder |
| Czech | hemoroidy, Hemoroidy, zlatá žíla |
| Finnish | Peräpukamat |
| Russian | GEMORROI, ГЕМОРРОЙ |
| French | HEMORROIDES, Hémorroïdes |
| Korean | 치질 |
| Polish | Hemoroidy, Żylaki odbytu, Guzki krwawnicze |
| Hungarian | Haemorrhoidok, Aranyerek, Aranyeres csomók |
| Norwegian | Hemoroider |
| Italian | Emorroidi |
