This document discusses hemorrhoids, including their anatomy, classification, risk factors, pathogenesis, clinical features, diagnosis, differential diagnosis, and management. Some key points: - Hemorrhoids are dilated submucosa vascular structures in the anal canal that can be internal, external, or mixed. Internal hemorrhoids are further classified into four grades based on degree of prolapse. - Risk factors include advancing age, diarrhea/constipation, pregnancy, prolonged sitting, and straining. Pathogenesis involves weakening of supporting tissues and increased pressure on hemorrhoids during defecation. - Clinical features depend on whether hemorrhoids are complicated or uncomplicated, and may include bleeding, pain,

1. Hemorrhoid
Mohammed AlHinai

2. Anatomy of anal canal

3. Hemorrhoids :
• Dilated submucosa vascular structures in the anal canal, arising by
Abnormal distension of the arteriovenous ( mainly arterial anastomoses
within the hemorrhoidal cushions
Hemorrhoids
External hemorrhoid
( located distal to
dentate line)
Internal hemorrhoids
(located proximal to
dentate line)
Mixed ( located both
proximal and distal
to dentate line)
- arise from the inferior
hemorrhoidal cushion.
- covered by modified
squamous epithelium (thick
layer).
- contains numerous somatic
pain receptors which
painful on thrombosis
- arise from the superior
hemorrhoidal cushion.
- three primary locations
(3,7,11) oclock position
- overlying columnar epithelium
(thin layer) is viscerally
innervated not sensitive to pain,
touch, or temperature

4. Classification of internal Hemorrhoids :
internal hemorrhoids are graded according to the degree to which they
prolapse from the anal canal.
Grade 1
• visualized on anoscopy and may bulge into the
lumen but do not prolapse below the dentate line
Grade 2
• prolapse out of the anal canal with defecation or
with straining but reduce spontaneously
Grade 3
• prolapse out of the anal canal with defecation or
straining, and require manual reduction
Grade 4
• irreducible and may strangulate

6. Risk factor:
• advancing age
• Diarrhea and chronic constipation.
• Pregnancy
• pelvic tumors
• prolonged sitting
• Straining
• patients on anticoagulation and antiplatelet therapy
Pathogenesis : multiple factor
• advancing age or aggravating conditions, the weakly anchored
hemorrhoids then gradually begin to bulge, and "slide" into the anal canal.
• by Hypertrophy or increased tone of the internal anal sphincter, the fecal
bolus forces the hemorrhoidal plexus against the internal sphincter during
defecation causes them to enlarge.
• Abnormal distension of the arteriovenous anastomoses within the
hemorrhoidal cushions
• Abnormal dilatation of the veins of the internal hemorrhoidal venous
plexus.

7. • Liver cirhosis not cause hemorrhoid but may associated with severe
bleeding through the hemorrhoid as coagulopathy.
• External hemorrhoid painful without bleeding as ( thick layer of muscosa )
and usually associated with thrombosis.

8. Clinical features:
History :
Age : occur any ages but uncommon below 20 years and extremely rare in
children.
Symptoms of internal hemorrhoids
Non-complicated complicated
Asymptomatic
(40%)
Bleeding :
- Painless
- Bright red blood coat
with stool at the end of
defecation or drip in
toilet.
- Associated with bowel
movement or
spontaneous.
- Exacerbated by straining
- Chronic bleeding cause
iron deficiency anemia
- Mild fecal
incontennece
- Mucus discharge
- Wetness or
fullness sensation
in perianal area in
case of prolapse
hemorrhoids
- Irritation or itching
in perianal skin.

9. Clinical features:
In complicated hemorrhoid :
• acute onset of perianal pain and a palpable perianal "lump" from thrombosis (
more common in external hemorrhoid).
• internal hemorrhoids become prolapsed, strangulated, and develop
gangrenous changes.
Diagnosis:
Clinical diagnosis Laboratory :
- For anemia.
Endoscopic evaluation :
- Including anoscopy and
colonoscopy.
- in all patient with malena
or hematochezia.
- all patient above 40y and
those who suspicious of
malignancy.

10. Differential diagnosis:
• anal fissures
• solitary rectal ulcer syndrome
• colorectal and anal cancer
• rectal prolapse
• polyps

11. Management: according to grade and complication
Hemorrhoids
- Internal hemorrhoid grade (1 – 2 )
- Internal hemorrhoid grade (3-4)
- external hemorrhoid
- Thrombosed inetrnal hemorrhoid
Conservative therapy Non surgical office-
based procedure (
rubber banding –
sclerotherapy ….)
No Definitive surgical
treatment
(hemorrhoidectomy)
No
Complication of banding :
commonly pain and infection
perianal skin irritation.
Bleeding less common
Complication: commonly
urinary retention
pain – infection - Bleeding
less common

12. Conservative treatments:
• High fiber diet to reduce constipation.
• oral or local analgesics to treat pain
• topical steroids agents to reduce local swelling or treat contact dermatitis (
hydrocortisol )
• therapies to reduce sphincter spasm
• venoactive agents to increase venous tone of hemorrhoidal tissues
• Sitz baths also help to relieve irritation and pruritus
• Change of Toilet habits.
Non surgical office-based procedure:
• Rubber banding
• Sclerotherapy : Injectable sclerosant solutions can also be used to treat
symptomatic internal hemorrhoids. causes an intense inflammatory reaction,
destroying redundant submucosal tissue associated with hemorrhoidal
prolapse.