AUTHOR INFORMATION

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Authored by David R Gurley, MD, Staff Physician, Department of Emergency Medicine, State University of New York at Downstate Medical Center, Kings County Hospital Center

Coauthored by Richard Sinert, DO, Associate Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, State University of New York College of Medicine; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center; Pilar Guerrero, MD, Instructor, Department of Emergency Medicine, Rowan Regional Medical Center

David R Gurley, MD, is a member of the following medical societies: American College of Emergency Physicians, and Society for Academic Emergency Medicine

Edited by William Gossman, MD, Assistant Professor, Department of Emergency Medicine, Rosalind Franklin University of Medicine and Science, Project Medical Director, Department of Emergency Medicine, Mount Sinai Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eugene Hardin, MD, FACEP, FAAEM, Chair and Associate Professor, Department of Emergency Medicine, Charles R Drew University of Medicine and Science; Chair, Department of Emergency Medicine, Martin Luther King, Jr/Drew Medical Center; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center

Author's Email:	David R Gurley, MD
Editor's Email:	William Gossman, MD

eMedicine Journal, April 20 2006, VOLUME 7, Number 4

INTRODUCTION

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Background: Hemorrhoidal disease is a common entity in the general population and in clinical practice. The most common cause of hematochezia in adults, it remains high in the differential diagnosis of almost any anorectal complaint.

Although hemorrhoids are very common, their true prevalence is unknown. Their presence may be underestimated due to the large proportion of relatively asymptomatic patients. Conversely, many nonspecific anorectal symptoms can be reflexively, and falsely, attributed to hemorrhoids without the appropriate workup.

The presentation of symptomatic hemorrhoids may be acute, chronic, or relapsing.

Pathophysiology: Hemorrhoids are a normal part of the human anorectum and arise from subepithelial connective tissue cushions within the anal canal.

Present in utero, these cushions surround and support distal anastomoses between the superior rectal arteries and the superior, middle, and inferior rectal veins. They also contain a subepithelial smooth muscle layer, contributing to the bulk of the cushions. Normal hemorrhoidal tissue accounts for approximately 15-20% of resting anal pressure and provides important sensory information, enabling the differentiation between solid, liquid, and gas.

Most people contain 3 of these cushions. Although classically described as lying in the right posterior (most common), right anterior, and left lateral positions, this combination is found in only 19% of patients. Hemorrhoids can be found at any position within the rectum.

Hemorrhoids are classified by their anatomic origin within the anal canal and by their position relative to the dentate line.

• Internal hemorrhoids develop above the dentate line from embryonic endoderm. They are covered by the simple columnar epithelium of anal mucosa and lack somatic sensory innervation.

• External hemorrhoids develop from ectoderm and arise distal to the dentate line. They are covered by stratified squamous epithelium and receive somatic sensory innervation from the inferior rectal nerve.

• Mixed hemorrhoids are confluent internal and external hemorrhoids.

Venous drainage of hemorrhoidal tissue mirrors embryologic origin:

• Internal hemorrhoids drain through the superior rectal vein into the portal system.

• External hemorrhoids drain through the inferior rectal vein into the inferior vena cava.

• Rich anastomoses exist between these 2 and the middle rectal vein, connecting the portal and systemic circulations.

Most symptoms arise from enlarged internal hemorrhoids. Abnormal swelling of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses. This leads to stretching of the suspensory muscles and eventual prolapse of rectal tissue through the anal canal. The engorged anal mucosa is easily traumatized, leading to rectal bleeding that is typically bright red due to high blood oxygen content within the arteriovenous anastomoses. Prolapse leads to soiling and mucus discharge (triggering pruritus) and predisposes to incarceration and strangulation.

Most clinicians use the grading system proposed by Banov et al in 1985, which classifies internal hemorrhoids by their degree of prolapse into the anal canal. This system both correlates with symptoms and guides therapeutic approaches.

• Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse.

• Grade II hemorrhoids may protrude beyond the anal verge with straining or defecating but reduce spontaneously when straining ceases.

• Grade III hemorrhoids protrude spontaneously or with straining and require manual reduction.

• Grade IV hemorrhoids chronically prolapse and cannot be reduced. They usually contain both internal and external components and may present with acute thrombosis or strangulation.

Frequency:

• In the US: Prevalence is estimated at 4.4% in the general population.

Race: Patients presenting with hemorrhoidal disease are more frequently white, from higher socioeconomic status, and from rural areas.

Sex: No predilection is known, although men are more likely to seek treatment.

Age: External hemorrhoids occur more commonly in young and middle-aged adults than in older adults. The prevalence of hemorrhoids increases with age, with a peak in persons aged 45-65 years. Symptomatic hemorrhoids also increase in pregnancy, possibly due to direct pressure on the rectal veins.

CLINICAL

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History: The most common presentation of hemorrhoids is rectal bleeding, pain, pruritus, or prolapse. However, these symptoms are extremely nonspecific and may be seen in a number of anorectal diseases. The physician must therefore rely on a thorough history to help narrow the differential and must perform an adequate physical examination (including anoscopy when indicated) to confirm the diagnosis.

• An adequate history should include the onset and duration of symptoms. In addition to characterizing any pain, bleeding, protrusion or change in bowel habits, special attention should be placed on the patient’s coagulation history and immune status.

• Bleeding is the most common presenting symptom. Blood is usually bright red and may drip or squirt into the toilet bowl. The physician should inquire about the quantity, color, and timing of any rectal bleeding. Darker blood or blood mixed with stool should raise suspicion of a more proximal cause of bleeding.

• A patient with a thrombosed external hemorrhoid may present with complaints of an acutely painful mass at the rectum (see Image 1). Pain truly caused by hemorrhoids usually arises only with acute thrombus formation. This pain peaks at 48-72 hours and begins to decline by the fourth day as the thrombus organizes. New-onset anal pain in the absence of a thrombosed hemorrhoid should prompt investigation for an alternate cause, such as an intersphincteric abscess or anal fissure. As many as 20% of patients with hemorrhoids will have concomitant anal fissures.

• The presence, timing, and reducibility of prolapse, when present, will help classify the grade of internal hemorrhoids and guide the therapeutic approach.

• Grade I internal hemorrhoids are usually asymptomatic, but at times may cause minimal bleeding.

• Grades II, III, or IV internal hemorrhoids usually present with painless bleeding but also may present with complaints of a dull aching pain, pruritus, or other symptoms due to prolapse.

• Familial predisposition, diet, history of constipation or diarrhea, and history of prolonged sitting or heavy lifting are also relevant, as are weight loss, abdominal pain, or any change in appetite or bowel habits. Presence of pruritus or any discharge should also be noted.

Physical: In addition to the general physical examination, physicians should also perform visual inspection of the rectum, digital rectal examination, and anoscopy or proctosigmoidoscopy when appropriate.
The preferred position for the digital rectal examination is the left lateral decubitus with the patient’s knees flexed toward the chest. Topical anesthetics (eg, 20% benzocaine or 5% lidocaine ointment) may help to reduce any discomfort caused by examination.

• External findings important to note include any of the following:

• Redundant tissue

• Skin tags from old thrombosed external hemorrhoids

• Fissures

• Fistulas

• Signs of infection or abscess formation

• Rectal or hemorrhoidal prolapse, appearing as a bluish, tender perianal mass

• During the digital rectal examination, assess for any masses, tenderness, mucoid discharge or blood, and rectal tone. Internal hemorrhoids are usually not palpable unless thrombosed.

• Current guidelines from most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of hemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.

Causes: Although many patients and clinicians believe that hemorrhoids are caused by chronic constipation, prolonged sitting, and vigorous straining, little evidence to support a causative link exists.

• Other risk factors historically associated with the development of hemorrhoids include the following:

• Pregnancy

• Lack of erect posture

• Familial tendency

• Higher socioeconomic status

• Chronic diarrhea

• Colon malignancy

• Hepatic disease

• Obesity

• Elevated anal resting pressure

• Spinal cord injury

• Loss of rectal muscle tone

• Rectal surgery

• Episiotomy

• Anal intercourse

• Varicosities caused from portal hypertension are a distinct entity from hemorrhoids.

DIFFERENTIALS

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Condyloma Acuminata
Inflammatory Bowel Disease
Proctitis
Rectal Prolapse

Other Problems to be Considered:

Anal cancer
Anal fissure
Anal fistula
Pedunculated polyp
Perianal abscess
Pruritus ani
Colorectal tumors

WORKUP

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Lab Studies:

• A CBC may be useful as a marker for infection. Anemia due to hemorrhoidal bleeding is rare (0.5 cases per 100,000 patients), and its presence should raise suspicion of an alternate diagnosis.

Imaging Studies:

• Proctogram may be indicated in rectal prolapse.

Procedures:

• Proctoscopy may be performed to supplement anoscopy.

• Full evaluation of the large bowel with colonoscopy is recommended for patients with significant abdominal symptoms, weight loss, change in bowel habits, age older than 50 years, or other risk factors for colonic malignancy.

TREATMENT

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Emergency Department Care: Medical management is the initial treatment of choice for grade I internal and nonthrombosed external hemorrhoids. It consists of sitz baths (bid/tid); a high-fiber diet; adequate fluid intake; stool softeners; topical and systemic analgesics; proper anal hygiene; and in some cases, a short course of topical steroid cream. Good evidence exists that high fiber diets in particular help reduce severity and duration of symptoms. The prolonged use of topical steroids should be avoided.

• Acutely thrombosed external hemorrhoids may be safely excised in the emergency department in patients who present within 48-72 hours of symptom onset.
  • Infiltration of a local anesthetic containing epinephrine is followed by elliptical incision and excision of the thrombosed hemorrhoid and overlying skin. Simple incision and clot evacuation is inadequate therapy and should not be performed.

  • The incision should not extend beyond the anal verge or deeper than the cutaneous layer. A pressure dressing is applied for several hours, after which time the wound is left to heal by secondary intention.

  • In patients presenting after 72 hours from the start of symptoms, conservative medical therapy is preferable.

• Internal hemorrhoids are treated according to their classification. Treatment may be surgical or nonsurgical. Most nonsurgical procedures currently available are performed in the clinic or ambulatory setting.
  • Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty foods.

  • Grade II or III hemorrhoids are initially treated with nonsurgical procedures.

  • Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy.

• Nonsurgical techniques function by ablation, sclerosis, or necrosis of mucosal tissues. Despite several meta-analyses and considerable personal preference, there is no clear advantage of one technique over the others.
  • Rubber band ligation is the most-used remedy for grade II and grade III hemorrhoids and is the standard to which other methods are compared. A band ligature is passed through an anoscope and placed on the rectal mucosa proximal to the dentate line. The tissue necroses and sloughs off in 1-2 weeks, leaving an ulcer that later fibroses. No anesthesia is required; complications are uncommon and usually benign.

  • Necrotizing pelvic sepsis is a rare, but serious, complication of rubber band ligation. The diagnosis is suggested by the triad of severe pain, fever, and urinary retention. It occurs 1-2 weeks after ligation, frequently in immune compromised patients, and requires prompt surgical debridement.

  • Infrared coagulation serves best for grade I, grade II, and some grade III hemorrhoids. It may be as effective as banding with fewer and less severe complications.

  • Bipolar electrocautery is best for lower-grade hemorrhoids; it quickly coagulates the hemorrhoid tissue but has no effect on prolapse.

  • Low-voltage direct current works best for higher grade hemorrhoids. Low-voltage direct current requires grounding time and provides excellent control of pain.

  • Sclerotherapy and cryotherapy are infrequently used today and generally reserved for type I or II hemorrhoids. Although minimally invasive, they have a higher rate of post-procedure pain. Impotence, urinary retention, and abscess formation have also been reported. Recurrence rates are as high as 30%.

  • Laser therapy is more costly and provides no advantage over other methods. Operators must control the laser to avoid bleeding.

• Contraindications to the nonsurgical treatments listed above include the following:
  • AIDS

  • Immunodeficiency disorders

  • Coagulopathy

  • Irritable bowel disease

  • Pregnancy

  • Immediate postpartum period

  • Rectal wall prolapse

  • Large anorectal fissure or infection

  • Tumor

• Surgical hemorrhoidectomy is the most effective treatment for all hemorrhoids and in particular is indicated in the following situations:
  • Nonsurgical treatment fails (persistent bleeding or chronic symptoms)

  • Grade III and IV hemorrhoids with severe symptoms

  • Presence of concomitant anorectal conditions (eg, anal fissure or fistula) requiring surgery

  • Patient preference

• About 5-10% of people with hemorrhoids will eventually require surgical hemorrhoidectomy. Postoperative pain remains the major complication, with most patients requiring 2-4 weeks before returning to normal activities. Other possible complications include urinary retention, anal stenosis, and incontinence.

Consultations: Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation.

MEDICATION

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The goals of therapy are to reduce pain and constipation.

Drug Category: Stool softeners -- These agents are used to avoid straining and constipation.

Drug Name	Docusate sodium (Colace) -- Indicated for patients who should avoid straining during defecation. Allows incorporation of water and fat into stool, causing stool to soften.
Adult Dose	50-500 mg/d PO qd or divided bid/qid
Pediatric Dose	<3 years: Not established 3-6 years: 20-60 mg/d PO qd or divided bid/qid 6-12 years: 40-150 mg/d PO qd or divided bid/qid >12 years: Administer as in adults
Contraindications	Documented hypersensitivity; nausea; vomiting; acute abdominal pain
Interactions	Decreases effects of warfarin; increases effects of phenolphthalein
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Prolonged use may result in electrolyte imbalance

Drug Category: Topical anesthetics -- These agents are indicated for pain.

Drug Name	Lidocaine ointment 5% (Lidoderm, Dermaflex) -- Decreases permeability to sodium ions in neuronal membranes, resulting in inhibition of depolarization, blocking transmission of nerve impulses.
Adult Dose	Apply to affected area prn
Pediatric Dose	Apply as in adults
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	For external or mucous membrane use only; do not use in eyes

Drug Category: Mild astringent -- This agent is used to relieve itching.

Drug Name	Hamamelis water (Witch Hazel) -- Mild astringent prepared from twigs of Hamamelis virginiana, used to temporarily relieve itching of hemorrhoids.
Adult Dose	Apply locally up to 6 times/d or following a bowel movement
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	A - Safe in pregnancy
Precautions	For external use only; avoid contact with eyes; discontinue treatment if condition worsens

Drug Category: Analgesics -- Pain control is essential to quality patient care. Analgesics ensure patient comfort, which is beneficial for patients who have painful lesions.

Drug Name	Acetaminophen (Tylenol, Aspirin Free Anacin, and Feverall) -- DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants. Reduces fever by direct action on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
Adult Dose	325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric Dose	<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d >12 years: 325-650 mg PO q4h; not to exceed 5 doses /24 h
Contraindications	Documented hypersensitivity; known G-6-P deficiency
Interactions	Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Hepatotoxicity can occur in chronic alcoholics following various dose levels of acetaminophen; severe or recurrent pain or high or continued fever may indicate serious illness

FOLLOW-UP

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Further Outpatient Care:

• After excision of a thrombosed external hemorrhoid, the patient may be discharged home for several hours of bedrest followed by sitz baths tid, stool softeners, and topical or systemic analgesia. The patient should return in 48-72 hours for a wound check.

• All other patients should be referred to a surgical or rectal clinic for more definitive treatment and sent home with conservative medical therapy.

Deterrence/Prevention:

• Avoid constipation

• Weight loss

• Avoid prolonged sitting on the toilet

• Avoid prolonged sitting at work

• Improved anorectal hygiene

Complications:

• Thrombosis

• Secondary infection

• Ulceration

• Abscess

• Incontinence

Prognosis:

• Most hemorrhoids resolve spontaneously or with conservative medical therapy alone.

• Recurrence rate with nonsurgical techniques is 10-50% over a 5-year period, while that of surgical hemorrhoidectomy is approximately 26%.

Patient Education:

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Hemorrhoids, Anal Abscess, Rectal Pain, and Rectal Bleeding.

TEST QUESTIONS

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CME Question 1: When is surgical hemorrhoidectomy indicated?

A: Grade I or grade II hemorrhoids
B: Severe grade III or grade IV hemorrhoids
C: Patient's request
D: Multiple hemorrhoids
E: Painful hemorrhoids

The correct answer is B: Hemorrhoids less severe than grade III should be treated conservatively.

CME Question 2: What is the most common presenting symptom of internal hemorrhoids?

A: Pain
B: Itching
C: Fecal staining
D: Painless rectal bleeding
E: Rectal mass

The correct answer is D: Internal hemorrhoids occur above the dentate line and are not innervated by pain fibers. Painless rectal bleeding is the most common presenting symptom of internal hemorrhoids.

Pearl Question 1 (T/F): Anemia is an expected laboratory finding in patients with internal hemorrhoids.

The correct answer is False: Anemia due to hemorrhoidal bleeding is rare; its presence should raise suspicion of an alternate diagnosis.

Pearl Question 2 (T/F): Right posterior is the most common site for internal hemorrhoids.

The correct answer is True: Right posterior is the most common site for internal hemorrhoids, although they may be found at any position within the rectum.

Pearl Question 3 (T/F): Necrotizing pelvic sepsis is a rare, but serious, complication of excising external hemorrhoids.

The correct answer is False: Necrotizing pelvic sepsis is a potentially serious complication of rubber band ligation. It usually presents in immune deficient patients 1-2 weeks after the procedure.

Pearl Question 4 (T/F): Contraindications to nonsurgical techniques (eg, banding, coagulation, laser) for treatment of grade II and grade III hemorrhoids include AIDS, coagulopathy, pregnancy, and anorectal infections.

The correct answer is True: Other contraindications include immediate postpartum period, irritable bowel disease, rectal wall prolapse, large anorectal fissure, or tumor.

PICTURES

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Caption: Picture 1. Thrombosed hemorrhoid. This hemorrhoid was treated by incision and removal of clot.
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BIBLIOGRAPHY

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• Billingham RP, Isler JT, Kimmins MH: The diagnosis and management of common anorectal disorders. Curr Probl Surg 2004 Jul; 41(7): 586-645[Medline].
• Fazio VW, Tjandra JJ: The management of perianal diseases. Adv Surg 1996; 29: 59-78[Medline].
• Janicke DM, Pundt MR: Anorectal disorders. Emerg Med Clin North Am 1996 Nov; 14(4): 757-88[Medline].
• MacKay D: Hemorrhoids and varicose veins: a review of treatment options. Altern Med Rev 2001 Apr; 6(2): 126-40[Medline].
• Madoff RD, Fleshman JW: American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology 2004 May; 126(5): 1463-73[Medline].
• Metcalf A: Anorectal disorders. Five common causes of pain, itching, and bleeding. Postgrad Med 1995 Nov; 98(5): 81-4, 87-9, 92-4[Medline].
• Parker GS: A new treatment option for grade II and IV hemorrhoids. J Fam Pract 2004 Oct; 53(10): 799-804[Medline].
• Perrotti P, Antropoli C, Molino D, et al: Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum 2001 Mar; 44(3): 405-9[Medline].
• Pfenninger JL, Surrell J: Nonsurgical treatment options for internal hemorrhoids. Am Fam Physician 1995 Sep 1; 52(3): 821-34, 839-41[Medline].
• Scaglia M, Delaini GG, Destefano I, Hulten L: Injection treatment of hemorrhoids in patients with acquired immunodeficiency syndrome. Dis Colon Rectum 2001 Mar; 44(3): 401-4[Medline].

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