Hemorrhoids

Background of hemorrhoids

Type	Clinical features
Definitions	*Hemorrhoid* Normal vascular structures from channel of arteriovenous connective tissues draining into superior and inferior hemorrhoidal veins Also known as “piles” *External hemorrhoid* Located distal to anal dentate line Arise from inferior hemorrhoidal plexus and covered by modified squamous epithelium with pain receptors *Internal hemorrhoid* Located proximal to anal dentate line Arise from superior hemorrhoidal plexus and can occur in left lateral, right anterior, or right posterior regions Covered by columnar epithelium without pain receptors *Mixed hemorrhoids* Located both proximal and distal to anal dentate line
Classification of internal hemorrhoids	*Grade I hemorrhoids* Can bulge into lumen without prolapsing below dentate line Visualized by anoscope *Grade II hemorrhoids* Prolapse out of anal canal with defection or straining Spontaneously go back into anal canal *Grade III hemorrhoids* Prolapse out of anal canal with defection or straining Requires manual reduction *Grade IV hemorrhoids* Prolapse out of anal canal continuously Cannot be reduced and may strangulate
Possible Pathogenesis of hemorrhoids	Deterioration of connective tissue anchoring hemorrhoids, which causes them to slide into anal canal Increased anal sphincter tone forcing hemorrhoidal plexus against internal sphincter Abnormal distention of arteriovenous anastomoses within the hemorrhoidal plexus Abnormal dilation of veins in hemorrhoidal plexus
Possible risk factors	Anticoagulation or antiplatelet therapy Chronic constipation Diarrhea Increasing age Pelvic tumors Pregnancy Prolonged sitting Prolonged straining

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