Hemorrhoids are defined as swollen veins in the anus or in the lower part of the rectum. The type of hemorrhoid depends on where it located. The major hemorrhoids types are internal hemorrhoids and external hemorrhoids.

Symptomatic hemorrhoids result from several factors that increase pressure within the abdomen and within the anal region. Some of these factors include constipation, straining when having a bowel movement, and irregular bowel patterns. Other common factors that elevate the risk of developing hemorrhoids include sedentary lifestyle, diarrhea, chronic straining during defecation, inadequate dietary fiber, and pregnancy.

Understanding of hemorrhoids pathophysiology is still incomplete and poorly investigated. The recent and most accepted theory is the theory of sliding anal canal lining. The theory states that disintegration and deterioration of supporting tissues of the anal cushions are the main reasons behind developing hemorrhoids. Hemorrhoids can be considered as a pathological term, which implies venous dilatation caused by the abnormal downward displacement of the anal cushions.

The symptoms of hemorrhoids depend on the type of hemorrhoids.In case of external hemorrhoids, the patient may develop constant and severe anal pain, tender and hard lumps near the anus, and anal itching. In case of internal hemorrhoids, the patient may develop bleeding from the rectum or prolapsed hemorrhoid.

In order to diagnose hemorrhoids, a physician may ask for medical history and may perform a physical examination. In addition, he/she may suggest procedures to examine anus and rectum such as with an anoscope and proctoscope.

Several treatment options are available for hemorrhoids including medications, lifestyle changes, and certain surgical interventions.If not well treated or managed, hemorrhoids can lead to several complications such as strangulated hemorrhoid and anemia.

Some preventive measures can be considered to prevent hemorrhoids such as consuming foods that rich in fibers, drinking enough water, and avoiding alcoholic liquids. Many symptomatic episodes of hemorrhoids can be treated with conservative measures; therefore, the prognosis is very good for individuals who suffer from hemorrhoids. The prognosis remains very good even if additional interventions carried out although recurrent symptoms may occur.

Hemorrhoids are inflamed and swollen veins in the anus or in the lower part of the rectum. Hemorrhoids are very common condition in both men and women. Presence of hemorrhoidal tissue is normal in all people. Only in a minority of people do hemorrhoids become enlarged and symptomatic. Hemorrhoids are caused mainly by increased pressure on the anus.

The type of hemorrhoid depends on where it located. Hemorrhoids may be inside or outside the body. The major hemorrhoids types are:

• Internal hemorrhoids: Develop in the veins inside the rectum. Internal hemorrhoids usually cause no pain but the hemorrhoids are susceptible to bleeding. The lining of internal hemorrhoids is covered with insensitive mucosa. The mucosa is insensitive to sensations such as temperature, touch, pain, or stretch. The classification of internal hemorrhoids depends on the degree of prolapse. The given grades or degrees for prolapsing of internal hemorrhoids are helpful in determining best treatment:

1.      Grade 1:     No prolapsing observed
2.      Grade 2:     Prolapse that returns in by its own
3.      Grade 3:     Prolapse that has to be moved back in by the patient
4.      Grade 4:     Prolapse that difficult to moved back in by the patient (mostly painful)

• External hemorrhoids: Develop in the veins outside the anus. This type of hemorrhoids can cause pain and itching, also, they can crack and bleed. The skin that covers external hemorrhoids is very sensitive.

Symptomatic hemorrhoids result from several factors that increase pressure within the abdomen and within the anal region. Some of these factors include:

• Aging-induced weakening of the supporting tissues in the anus and rectum,
• Sitting for prolonged time, especially on the toilet,
• Straining when having a bowel movement,
• Certain diseases, such as liver cirrhosis,
• Constipation and diarrhea,
• Consuming low-fiber diet,
• Irregular bowel patterns,
• Lifting heavy weights,
• Pregnancy (in females),
• Obesity.

Constipation, spice or alcohol intake are risk factors for the hemorrhoidal crisis. Other common factors considered to elevate the risk of developing hemorrhoids include sedentary lifestyle, diarrhea, chronic straining during defecation, inadequate dietary fiber, and pregnancy.Also, being older than age 50, chronic cough, certain hereditary factors can be regarded as possible risk factors.

Understanding of hemorrhoids pathophysiology is still incomplete and require more investigation. Theory of varicose veins has its roots in the medical literature.The theory states that hemorrhoids are the result of varicose veins in the anal canal; however, the recent studies have rejected the theory because hemorrhoids and anorectal varices are confirmed to be separate disorders.

Furthermore, the belief in increasing incidence of hemorrhoids in patients who suffer from portal hypertension and varices has no observational evidence to support it. The recent and most accepted theory is the theory of sliding anal canal lining. The theory states that disintegration and deterioration of supporting tissues of the anal cushions are the main reasons behind developing hemorrhoids.

Hemorrhoids can be considered as a pathological term which implies venous dilatation caused by the abnormal downward displacement of the anal cushions. The three major anal cushions are located usually in the right anterior, right posterior and left lateral aspect of the anal canal.

However, several numbers of minor cushions can be observed lying between the major three cushions. Considerable pathological changes have been observed in the anal cushions of patients who suffer from hemorrhoids. The observed changes include distortion and rupture of the anal subepithelial muscle, vascular thrombosis, abnormal venous dilatation, and degenerative process in the collagen fibers and fibroelastic tissues.

The symptoms of hemorrhoids depend on the type of hemorrhoids.

In case of external hemorrhoids, the patient may have:

• Constant and severe anal pain, especially when sitting. Sometimes the increased pressure in the thrombosed external hemorrhoid can cause clotted blood leaking and overlying skin collapsing.
• Tender and hard lumps near the anus that vary in number
• Anal itching

Symptoms of hemorrhoids can get worse by excessive straining, rubbing, or cleaning around the anus.

In case of internal hemorrhoids, the patient may have:

• Bleeding from the rectum that can manifest by bright red blood on stool or on toilet paper. Patients may also notice mucus discharge and may have the sense that the stool is “stuck” at the anus with bowel movements or difficulty with cleaning themselves after a bowel movement.
• Prolapsed hemorrhoid which is a hemorrhoid that has fallen through the anal opening.

Internal hemorrhoids which not prolapsed often are not painful. However, prolapsed internal hemorrhoids may result in pain and discomfort.

In order to diagnose hemorrhoids, a physician may ask for medical history and may perform a physical examination. In addition, he/she may suggest procedures to examine anus and rectum such as with an anoscope and proctoscope.

• Medical history: Physician may ask questions concerning current medical conditions, enema, and laxative use as well as eating and toilet habits.
• Physical examination: External hemorrhoids diagnosed by checking the area around the anus. The experienced physician may be able to diagnose external hemorrhoids simply by looking. A physician may perform a digital rectal exam which done by placement of a finger through the anus into the rectum to diagnose internal hemorrhoids. Also, a physician  may check the area around the anus to search for :

1. Skin tags which were known as an extra skin that formed after dissolving of a blood clot in external hemorrhoids.
2. Anal fissures which known as a small rupture in the anus that may result in itching, pain, or bleeding.
3. Prolapsed hemorrhoid, which falls through the anal opening (in internal hemorrhoids).
4. A blood clot in a vein (in external hemorrhoids).
5. Skin irritation, lumps or swelling.
6. Leakage of stool or mucus.

• Procedures: Physician may propose the following procedures to diagnose internal hemorrhoids:

1. Anoscopy: Physician uses an anoscope to examine the lining of the anus and lower rectum to detect signs of lower digestive tract problems and bowel disease.
2. Rigid proctosigmoidoscopy: Rigid proctosigmoidoscopy shares similar features with anoscopy, except that the physician uses a different tool called proctoscope that allows him to view the lining of the rectum and lower colon.

A physician may suggest further examination for the colon to distinguish polyps, cancers, and other causes of bleeding.  A flexible sigmoidoscopy can be used to facilitate visualizing half of the colon, while a colonoscopy can be used to visualize the entire colon.

There are a variety of options to treat hemorrhoid, including :

• Medications :

• Taking over-the-counter corticosteroid (e.g. cortisone) creams to help reduce pain and swelling
• Taking stool softeners that help loosen stools to decrease  straining and constipation
• Taking lidocaine creams to help reduce hemorrhoids pain

• Procedures and Surgeries

1. Rubber band ligation: This procedure is used mainly to treat bleeding or prolapsing internal hemorrhoids. The procedure performed to cuts off the blood supply and causes the hemorrhoid to fall off by placing a tiny rubber band around an internal hemorrhoid.
2. Sclerotherapy: This procedure is used to break down hemorrhoid by injecting a chemical solution into the vein and used also to treat varicose veins. The injection is painless but the procedure is considered less effective than rubber band ligation. However, sclerotherapy is an office-based treatment that used to treat grades 1 and 2 internal hemorrhoids.
3. Doppler-guided hemorrhoidal artery ligation: This is relatively a new procedure to help treat hemorrhoids. As the name suggests, doppler guided hemorrhoidal artery ligation is performed by ligation of the distal branches of the superior rectal artery. The ligation of the artery will lead to the reduction of blood flow and decongestion of hemorrhoidal plexus resulting in fibrosis.
4. Diode laser: Some of the advantages associated with laser surgery include less operation time, speeds healing time, less pain, and less bleeding. Compared to open hemorrhoidectomy, some researchers confirming that diode laser energy delivered into small to median hemorrhoidal piles can cause little pain and can lead to a partial to complete recovery within a shorter time.
5. Infrared photocoagulation: Infrared coagulation (IRC) is an office-based procedure which can be performed during anoscopy. This procedure can help treat grades 1 and 2 and occasional grade 3 internal hemorrhoids. In this procedure, the physician will use an instrument that directs infrared light at an internal hemorrhoid.  The used energy is converted to heat and causes the hemorrhoidal tissue to become inflamed and help eliminate the excess tissue.
6. Electrocoagulation:  In this procedure, the physician will use an internment that sends an electric current into an internal hemorrhoid to cuts off the blood supply by forming scar tissue.

• Surgery :If other options fail, the physician may suggest one of the invasive surgical procedures such as :

1. Hemorrhoid removal: This procedure is known also as hemorrhoidectomy. Hemorrhoidectomy is an effective surgical procedure to treat severe or recurring hemorrhoids. In this surgical procedure, the surgeon will remove excess tissue that causes bleeding.
2. Hemorrhoid stapling: This procedure is known also as stapled hemorrhoidectomy or stapled hemorrhoidopexy and is used only for internal hemorrhoids by blocking blood flow to hemorrhoidal tissue. The surgeon uses a special stapling tool primarily to remove internal hemorrhoid tissue and to return a prolapsing internal hemorrhoid back into the anus. However, greater risk of recurrence and rectum protrudes from the anus (rectal prolapse) have been associated with stapling.

• Home remedies and lifestyle changes include :
• Sitting in a warm bath for a period of time as the physician suggest (or use a sitz bath which designed specifically for hemorrhoids patients), usually for 10 to 15 minutes, 1 to 2 times per day.
• Avoiding pressure on the area and straining during bowel movements (e.g. sitting on an inflatable ring).
• Keeping the anal area clean and decrease the amount of time spent in the toilet.
• Avoiding dry toilet tissue with perfumes or colors.
• Consuming foods that are high in fiber.
• Wearing cotton undergarments.
• Avoiding the scratch of the area.
• Using ice or cold packs.

Complications of hemorrhoids can include the following:

• Strangulated hemorrhoid that occurs when the muscles around the anus impede the blood supply to a prolapsed hemorrhoid.
• Infection and blood clots (in external hemorrhoid).
• Skin tags and anemia.
• Ischaemia and thrombosis.
• Ulceration of thrombosed external hemorrhoids.

Constipation has to be prevented to reduce straining when having a bowel movement. In addition, hemorrhoids generally can be prevented by the following:

1. Avoiding laxatives, except bulk-forming laxatives such as Fiberall and Metamucil. The other types of laxatives can lead to diarrhea, which can worsen hemorrhoids.
2. Avoiding sitting on the toilet for too long but when the urge to have a bowel movement come, it is not recommended to wait for too long to use the bathroom.
3. Drinking enough water and avoiding alcoholic liquids each day (as recommended by a health expert).
4. Reducing straining during bowel movements and avoiding regular heavy lifting.
5. Consuming foods that rich in fibers such as Raspberries and whole-wheat.

Generally speaking, many symptomatic episodes of hemorrhoids can be treated with conservative measures, therefore the prognosis is very good for individuals who suffer from hemorrhoids. The prognosis remains very good even if additional interventions carried out although recurrent symptoms may occur.

Prolapsed hemorrhoid reduces spontaneously in the early clinical course of the hemorrhoidal disease. In the later clinical course of the hemorrhoidal disease, the prolapsed hemorrhoid may need manual reduction and may result in mucus discharge, which can cause irritation of the skin at the anus. Internal hemorrhoids cause no pain usually unless prolapse occurs. However, thrombosed external hemorrhoids may cause pain.

The majority of hemorrhoids treatments are effective in treating most of the cases. The patient should inform his physician if the hemorrhoids persist after 1 to 2 weeks. The blood in the enlarged veins may form clots resulting in death of the tissue surrounding the hemorrhoids. Surgical intervention is required for hemorrhoids –induced clots. Severe bleeding may also occur, although it is unusual, however, death from hemorrhoidal bleeding is rare. Hemorrhoids in pregnancy usually resolve after delivery.

Epidemiological data on the prevalence of hemorrhoids are rare because many patients ignore their problems or keep consuming over-the-counter prescriptions. The following is a part of the available hemorrhoids related data:

• According to a study published in the International Journal of Colorectal Disease, hemorrhoids can be found predominantly in the adult general population. The majority of people with hemorrhoids do not complain about symptoms. In addition, the study confirms that being obese can be regarded as an independent risk factor for hemorrhoids.
• According to a study published in Gastroenterology Journal, 10 million people in the United States suffer from hemorrhoids, with a prevalence rate of 4.4%. Noticeable peak in prevalence was reported from age 45-65 year in both males and females, and the prevalence decrease after age 65 years.
• According to a study published in Clinics in Colon and Rectal Surgery Journal, when hemorrhoids patients failed or unable to tolerate non-operative treatments, approximately 5 to 10% of them will require a formal excision or hemorrhoidectomy.