Hemorrhoids
Commonly painful, hemorrhoids are varicosities in the superior or inferior hemorrhoidal venous plexus. Dilation and enlargement of the superior plexus produce mucosa-covered, internal hemorrhoids that bulge into the rectal lumen and may prolapse during defecation. Dilation and enlargement of the inferior plexus produce skin-covered, external hemorrhoids that may protrude from the rectum. External hemorrhoids are more likely to be thrombotic than internal hemorrhoids. Generally, the incidence of hemorrhoids peaks between ages 20 and 50 and affects both sexes.
Causes
Hemorrhoids probably result from increased intravenous pressure in the hemorrhoidal plexus. Predisposing factors include heart failure, alcoholism, anorectal infections, pregnancy, anal intercourse, and occupations that require prolonged standing or sitting. Other factors include hepatic disease, such as cirrhosis, amoebic abscesses, or hepatitis; loss of muscle tone due to old age, rectal surgery, or episiotomy; and straining due to constipation, diarrhea, coughing, sneezing, or vomiting.
Complications
Local infection or thrombosis of hemorrhoids may occur. Rarely, hemorrhoids cause severe or recurrent bleeding, leading to secondary anemia with significant pallor, fatigue, and weakness.
Assessment
Typically, the patient notices and reports intermittent rectal bleeding after defecation. He may report bright red blood on his stools or toilet paper—a sign that the fragile mucosa covering the hemorrhoid was injured during defecation. He may also complain of anal itching (the result of poor anal hygiene) or describe a vague feeling of anal discomfort when bleeding occurs.
If the hemorrhoids are thrombosed, the patient usually complains of rectal pain, which may be accompanied by anal pruritus and mucus discharge. If external hemorrhoids are thrombosed, he may be aware of a large subcutaneous lump in the anal area.
Inspection of the anal area confirms the presence of external hemorrhoids. If the external hemorrhoids are thrombosed, they appear on inspection as blue swellings at the anus. Although internal hemorrhoids aren’t usually seen on inspection, prolapsed hemorrhoids are visible.
Palpation reveals anal tenderness. Digital rectal examination may detect internal hemorrhoids.
