Hemorrhoids Update Review

Archive for the ‘Hemorrhoids’ Category

In the upper anal canal, the hemorrhoids cushions are composed of three submucosal pillars of sinusoids within connective tissue, generally in the left lateral, right anterior, and right posterior. During the act of defecation, the hemorrhoids cushions become engorged with blood, cushioning the anal canal and supporting the anal canal lining. The pathologic term hemorrhoids is used to describe the downward displacement of the cushion along with dilation of the contained sinusoids and sometimes bleeding from the arteriole, venule, or sinusoidal portion.Hence, hemorrhoids develop when the supporting tissues of the anal cushion deteriorate or with extensive downward pressure, as in prolonged straining at stool or pregnancy.

The most common complaints of burning, itching, swelling, and pain usually are not from hemorrhoids but result from pruritus ani, anal abrasion, anal fissure, thrombosed external hemorrhoids, or prolapsed anal papilla. Symptoms are aggravated by constipation and diarrhea. The most common manifestation of hemorrhoids is painless, bright red rectal bleeding associated with bowel movement. With severe hemorrhoids,the patient commonly describes the bleeding episode as blood dripping into the toilet bowl. A feeling of incomplete evacuation is also common. In chronic prolapse, exposed rectal mucosa often causes perianal irritation and mucus staining on the underwear. Congestion of external hemorrhoids or skin tags can cause discomfort. Except in the presence of thrombosis, pain is rarely an early symptom of hemorrhoidal disease and other diagnoses should be excluded.

About hemorrhoids ,there are few diseases that are more chronicled in human history than symptomatic hemorrhoidal disease.References occur in ancient texts dating back to Babylonian, Egyptian, Greek, and Hebrew cultures. Included in many of these writings are multiple recommended treatment regimens such as anal dilatation, topical ointments, and the intimidating red-hot poker. Although few persons have died of hemorrhoidal disease, many patients have wished they had, particularly after therapy; this fact led to the beatification of St. Fiacre, the patron saint of gardeners and hemorrhoidal sufferers. This discussion should guide the practitioner in a more humane approach to hemorrhoidal disease with an emphasis on cost effectiveness and minimal complications.

The hemorrhoidal cushions appear predictably in the right anterior, right posterior, and left lateral positions, although there may be intervening secondary hemorrhoidal complexes that blur this classic anatomy. The blood supply is similarly constant, derived from the superior rectal artery, a branch of the inferior mesenteric; from the middle rectal arteries arising from the internal iliac arteries; and from the inferior rectal arteries arising from the pudendal arteries. The venous drainage transitions from the portal venous system above the level of the dentate line to the systemic venous system below this level.

The vascular cushions form the termination of the vascular supply within the anal canal and contribute to the maintenance of anal continence.[6] hemorrhoids occurs as the result of abnormalities within the connective tissue of these cushions, producing bleeding with or without prolapse of the hemorrhoidal tissue.[7] This can occur as the result of excessive straining and chronic constipation.[8] A clear understanding of the pathophysiology is important when considering therapeutic interventions. At the earlier stages of disease progression, when the major manifestation is transudation of blood through thin-walled damaged veins or arterioles, ablation of the vessels should be adequate. Conversely, in late stages of the disease, when there is significant disruption of the mucosal suspensory ligament, fixation of the mucosa to the underlying muscular wall is required for effective therapy.Internal anal sphincter dysfunction may play a role; a number of investigators have demonstrated increased internal anal sphincter tone in patients with hemorrhoids. In reality, a combination of all of these factors is probably important for the ultimate development of large prolapsing internal hemorrhoids.