Hemorrhoids

Classification and Diagnosis

• Internal hemorrhoids are located above the dentate line, covered by rectal mucosa, and require anoscopy for proper visualization, with a classification system endorsed by the American Society of Colon and Rectal Surgeons:

  Degree	Description
  First-degree	Bleeding without prolapse
  Second-degree	Prolapse during defecation with spontaneous reduction
  Third-degree	Prolapse requiring manual reduction
  Fourth-degree	Irreducible prolapse

  1, 2

• External hemorrhoids are located below the dentate line, covered by anoderm and perianal skin, visible during external examination, and can be painful due to somatic innervation 1, 2
• Anoscopy is essential for proper visualization and diagnosis of internal hemorrhoids, as digital rectal examination cannot reliably detect them 3

Examination Techniques

• The World Journal of Emergency Surgery guidelines recommend performing anoscopy as part of the physical examination for hemorrhoids whenever feasible and well tolerated 3
• External inspection and digital rectal examination should be performed to check for visible prolapsed tissue, external hemorrhoids, masses, and tenderness, but anoscopy is necessary for visualizing internal hemorrhoids 3
• A thorough anorectal examination, including anoscopy, is essential for accurate diagnosis 3, 1, 2

Risk Factors and Prevention

• Inadequate fiber intake, prolonged sitting on the toilet, chronic straining during defecation, constipation, and diarrhea are risk factors for developing hemorrhoids 1
• Pregnancy is a significant risk factor, with approximately 80% of pregnant persons developing hemorrhoids, particularly in the third trimester 1, 4
• Family history suggests a possible genetic predisposition to hemorrhoids 1
• Increasing dietary fiber intake to approximately 30g/day, ensuring adequate fluid intake, avoiding prolonged sitting on the toilet, and addressing constipation can help prevent hemorrhoids 1, 4
• Using relaxation techniques and avoiding straining during bowel movements can also help prevent hemorrhoids 4

Symptoms and Evaluation

• Symptoms of hemorrhoids include bleeding, protrusion, itching, and pain, with external hemorrhoids typically being asymptomatic unless thrombosed, and internal hemorrhoids causing bright red bleeding due to arterial oxygen tension from arteriovenous communications 1
• The minimum standard for evaluating rectal bleeding includes anoscopy and flexible sigmoidoscopy for bright-red rectal bleeding, and a complete colonic evaluation is indicated when bleeding is atypical or risk factors for colorectal cancer are present 1
• Risk factors for colorectal cancer that warrant a complete colonic evaluation include dark blood, positive fecal occult blood test, anemia, age over 50 years, and family history of colorectal cancer 1, 2

Treatment and Management

• The American Gastroenterological Association recommends treatment for hemorrhoids based on severity, with first-degree hemorrhoids treated with medical therapy, second and third-degree hemorrhoids treated with non-operative techniques, and fourth-degree hemorrhoids requiring surgical intervention 2
• Thrombosed external hemorrhoids are best managed by excision under local anesthesia if diagnosed early (within 72 hours of symptom onset), while small third-degree hemorrhoids may be manageable with non-operative methods like rubber band ligation, as recommended by the American Society of Colon and Rectal Surgeons 1, 2

Epidemiology

• The peak prevalence of hemorrhoids occurs between 45-65 years of age, with up to 0.2% of pregnant women requiring urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids, and the community-wide prevalence of hemorrhoids in the United States is approximately 4.4% 1