Hemorrhoids

Hemorrhoids (US English) or haemorrhoids UK /ˈhɛmərɔɪdz/, are vascular structures in the anal canal which help with stool control. They become pathological or piles when swollen or inflamed. In their normal state, they act as a cushion composed of arterio-venous channels and connective tissue.

The symptoms of pathological hemorrhoids depend on the type present. Internal hemorrhoids usually present with painlessrectal bleeding while external hemorrhoids may produce few symptoms or if thrombosed significant pain and swelling in the area of the anus. Many people incorrectly refer to any symptom occurring around the anal-rectal area as "hemorrhoids" and serious causes of the symptoms should be ruled out.^[4] While the exact cause of hemorrhoids remains unknown, a number of factors which increase intra-abdominal pressure, in particular constipation, are believed to play a role in their development.

Initial treatment for mild to moderate disease consists of increasing fiber intake, oral fluids to maintain hydration,NSAIDs to help with the pain, and rest. A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management. Surgery is reserved for those who fail to improve following these measures. Up to half of people may experience problems with hemorrhoids at some point in their life. Outcomes are usually good.

Surgery

A number of surgical techniques may be used if conservative management and simple procedures fail. All surgical treatments are associated with some degree of complications including bleeding, infection, anal strictures and urinary retention, due to the close proximity of the rectum to the nerves that supply the bladder. There may also be a small risk of fecal incontinence, particularly of liquid, with rates reported between 0% and 28%. Mucosal ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis). This is where the anal mucosa becomes everted from the anus, similar to a very mild form ofrectal prolapse.

• Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily only in severe cases. It is associated with significant post-operative pain and usually requires 2–4 weeks for recovery. However, there is greater long term benefit in those with grade 3 hemorrhoids as compared to rubber band ligation.It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24–72 hours. Glyceryl trinitrate ointment post procedure, helps both with pain and healing.
• Doppler-guided, transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate, but fewer complications compared to a hemorrhoidectomy.
• Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy, is a procedure that involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids. However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorroidectomyand thus it is typically only recommended for grade 2 or 3 disease.

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