Hemorrhoids are normal anal cushions that help with continence. They become symptomatic when the veins and connective tissue deteriorate, causing swelling. Hemorrhoids are either internal or external. Internal hemorrhoids are more common and cause bleeding but not pain, while external hemorrhoids cause pain but rarely bleed. Hemorrhoids are graded based on severity from stage 1 with no prolapse to stage 4 that cannot be reduced. Treatment depends on the stage but may include lifestyle changes, creams, banding or surgery.

1. Hemorrhoids
By Sobhan Pouramini

2. Anatomy
 Anorectal Junction → Anal Verge
 Pectinate Line and Anal Valves
 Anal Columns of Morgagni (Lithotomy: III,
VII, XI)
 Upper 2/3 (Cloaca) vs Lower 1/3 (Anal Pit)
• Autonomic vs Somatic innervation
• Superior vs Middle and Inferior Rectal
Arteries
• Internal vs External Venous Plexus (Anulus
Hemorrhoidalis)
• Portocaval Anastomosis

3. Histology
 Hemorrhoids (“piles” or “cushions”) are normal anatomic structures
consisting of:
1-Epithelial Lining:
Mucosa (internal hemorrhoids) vs Anoderm (external hemorrhoids)
2-Submucosa (supporting connective tissue)
3-Vascular Structures (Arterioles, Venules, AV Shunts or Sinusoids):
Retrorectal Plexus (SRA, MRA) → Right Anterior, Right
Posterior, Left Terminal Branches (III, VII, XI)
Internal venous plexus → Internal Hemorrhoids
External venous plexus → External Hemorrhoids
4-Ligament of Treitz:
Anal Submucosal Muscle: Cushions → Int S
Suspensory (Park’s) Ligament: Penetrates Int S, Attaches to L. Muscle

4. Primary and Secondary Piles Anchoring Fibers (of Treitz)

5. Physiology
 Functions of Hemorrhoids Include:
 Anal Continence (15-20% of normal pressure,
closes 7-8 mm gap), proposed by Stelzner :
• Contraction of Int S (during rest) → Reduced
Venous Return → Enlargement of Cushions Seals
Anal Canal
• During Defecation: Int S Relaxes (Increased
Venous Return), Treitz’s Muscle Contracts, Stool
inserts pressure
• During Sneezing or coughing: Increased
Intraabdominal Pressure → Increased Pressure in
IVC → Reduced Venous Return, Cushions Engorge
 Helps differentiate stool, liquid and gas in anal
canal (Via ENS)

6. Pathophysiology
 Central Hallmark of hemorrhoidal disease (Symptomatic)
is the swelling of sinusoids
Core Etiologies:
1- Reduction of venous return due to increased
intraabdominal pressure (congestion)
Risk Factors: Obesity, Pregnancy (pressure, hormones),
Straining, Sitting position during defecation, constipation,
portal hypertension*
2- Deterioration of connective tissue resulting in prolapse
of cushions
Degeneration of Treitz’s Muscle
Abnormalities in Collagen or Elastic Fibers (causes
congestion)
Risk Factors: Normal Aging, Diarrhea, Genetics (Ehlers-
Danlos Syndrome, Scleroderma)

7. Hemorrhoids are not related to portal hypertension!

8. Internal Vs External
Hemorrhoids
 Internal
• More common
• Distension does not cause pain (Strangulation causes pain)
• Frequently Bleed (Bright red, Arterial)
• Usually prolapse
• Can’t be palpated
• Accompanied by itching and soiling of underwear (mucus
secretion)
• Can cause incontinence (lack of sensation, prolapse blocks
Ext S)
 External
• Less common
• More likely to thrombose, resulting in extreme pain
• Can generally be seen and palpated

9. Stages of Disease
 Global Disease Prevalence: 4.4%
 Grade 1
Bleeding, No Prolapse
 Grade 2
Prolapse, Reduces Spontaneously
 Grade 3
Prolapse Requires Manual Retraction
 Grade 4
Prolapse Cannot Be Reduced
Usually Also Have External Hemorrhoids

10. Diagnosis
1- Perform detailed history
• Bowel habits
• Rectal pain, itching, bleeding
• Statis of Malignancy, IBS, Continence
2- Perform anorectal examination
• Visual examination of perianal skin
• Digital examination via anoscope
3- Examine rectum, sigmoid colon and colon
• Proctoscopy, Rectoscopy, Colonoscopy, CT
• Risk Factors: Inconclusive anorectal examination,
Age ≥ 50 (Red Flag for Colorectal Cancer)

11. Treatment
General Treatments
• Life style modifications (To reduce straining)
• Sitz Bath (short-term relief)
• Topical Medication such as glyceryl trinitrate,
Nifedipine (Calcium-channel blocker)
Treatment of Internal Hemorrhoids
• Grade I-III: Office-Based Procedures (Rubber
Band Ligation)
• Grade IV: Surgery (Hemorrhoidectomy, Stapled
Hemorrhoidopexy)
Treatment of External Hemorrhoids
• Drainage of Blood from cushion
• Hemorrhoidectomy (Up to 72h)

12. References
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6479658/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8057569/
• https://pubmed.ncbi.nlm.nih.gov/6745015
• https://www.sciencedirect.com/science/article/abs/pii/S1043148907000292
• www.mayoclinic.org
• www.imaios.com
• www.amboss.com
• www.thenurseszone.com
• www.kenhub.com
• www.colorectalcentre.co.uk

13. THANK YOU