Bright red, painless rectal bleeding during defecation is the most common presentation [4]. Other symptoms include [7] anal itching, anal or pelvic pain especially during sitting, one or more palpable lumps that feel hard, congested and tender. There may also be complains of sudden, sharp pain during bowel movements that subsides eventually.

• Perineal Pain

  The recurrence rate after 2 years was 18.3%, and complications included pyrexia, low blood pressure, perineal pain and rectal ulcers, but those were mild [ 17 ]. [ncbi.nlm.nih.gov]

• Veterinarian

  Yes, but you have to consult a veterinarian immediately. [mboard.pcaarrd.dost.gov.ph]

• Pneumonia

  Embolism / Thrombotic events / Venous Thromboembolism 1 2 Terminated Treatment Acute Chest Syndrome / Sickle Cell Disorders 1 2 Terminated Treatment Angioplasty / Coronary Artery Disease / Percutaneous Coronary Intervention 1 2 Terminated Treatment Pneumonia [drugbank.ca]

• Sore Throat

  Call your health care provider right away if: You have signs of a cold or the flu, like sneezing, coughing, a sore throat, fever or minor aches. A nosebleed lasts longer than 20 minutes. You get a nosebleed after an injury to your head. [marchofdimes.org]

• Constipation

  This can occur during pregnancy or childbirth, and due to constipation. The pressure causes the normal anal veins and tissue to swell. This tissue can bleed, often during bowel movements. [nlm.nih.gov]

  Abstract A new syndrome in which 7 cases share common clinical features of urethral discharge only at defecation, constipation, and hemorrhoids is reported. The discharge occurred only with constipation. [ncbi.nlm.nih.gov]

  In general, anything that puts pressure on the veins in the lower body can lead to hemorrhoids, including straining during a bowel movement; sitting on the toilet for long periods; constipation or diarrhea; being overweight; pregnancy; and age, which [jamanetwork.com]

• Rectal Bleeding

  Other questions may be asked to look for other causes of rectal bleeding including tumors, inflammatory bowel disease, and gastrointestinal bleeding. [medicinenet.com]

  In a 62-yr-old woman who complained of recurrent rectal bleeding, hemorrhoids with mucosal prolapse were found. Virus-related cirrhosis also was present. [ncbi.nlm.nih.gov]

  Rectal lump; Piles; Lump in the rectum; Rectal bleeding - hemorrhoids; Blood in the stool - hemorrhoids Abdelnaby A, Downs JM. Diseases of the anorectum. In: Feldman M, Friedman LS, Brandt LJ, eds. [nlm.nih.gov]

  Hemorrhoid Symptoms Symptoms of hemorrhoids can include the following: Painless rectal bleeding Itching or pain in the anal region Protrusion of tissue (a hemorrhoid) through the anus Leakage of feces Rectal bleeding Painless rectal bleeding with a bowel [gastroconsa.com]

• Pruritus Ani

  Table 7 Distribution of pruritus ani stages in 317 patients with pruritus ani and comparison of pruritus ani stages in 155 patients with exclusive pruritus ani vs.162 patients with MAL Stages of pruritus ani Total number (%) of patients with pruritus [ncbi.nlm.nih.gov]

  However, in more than one half of patients with pruritus ani the cause is categorized as idiopathic. Table 1 Etiologies of pruritus ani. [dx.doi.org]

• Rectal Pain

  Common Causes of Rectal Pain The four common causes of the symptom of rectal pain, pressure, or discomfort are hemorrhoids, anal fissures, fleeting anal spasms (Proctalgia fugax), and other more constant muscle spasms (Levator ani syndrome). [emedicinehealth.com]

  Rectal bleeding and pain and recent changes in bowel habits are also symptoms of colon, rectal, or anal cancer. [northshore.org]

• Fecal Incontinence

  Straining during bowel movements can eventually weaken anal sphincter muscles or damage nerves, possibly leading to fecal incontinence. Fecal incontinence care at Mayo Clinic Oct. 12, 2018 References Fecal incontinence. [mayoclinic.com]

  Other problems that may arise include bleeding after the operation, wound infections, abscesses, narrowing of the anus (anal stenosis), and – rarely – fecal incontinence. Fecal incontinence is the inability to control bowel movements. [informedhealth.org]

  In Group II, 2 patients reported fecal incontinence as a consequence of surgery. [dx.doi.org]

  Rockwood TH, Church JM, Fleshman JW et al (2000) Fecal Incontinence Quality of Life Scale: quality of life instrument for patients with fecal incontinence. Dis Colon Rectum 43:9–16; discussion 16-17 [ PubMed ] 12. [ncbi.nlm.nih.gov]

• Pruritus

  Table 7 Distribution of pruritus ani stages in 317 patients with pruritus ani and comparison of pruritus ani stages in 155 patients with exclusive pruritus ani vs.162 patients with MAL Stages of pruritus ani Total number (%) of patients with pruritus [ncbi.nlm.nih.gov]

  However, in more than one half of patients with pruritus ani the cause is categorized as idiopathic. Table 1 Etiologies of pruritus ani. [dx.doi.org]

• Eczema

  Pruritus.FACTSHEET HELPLINE: eczema, please visit the NES genital eczema frequently affects the skin around the opening.Pruritus ani or itchy bum, labial eczema. January 27, 2014 by RuthS 10 Comments. [xigujafey.xpg.uol.com.br]

  Flare-up of hand eczema is common in sensitive individuals if they use or consume products containing Balsam of Peru or related allergens. Oral exposure may cause sore mouth (tongue) and rash of the lips or angles of the mouth. [dermnetnz.org]

  Christopher's Healing Ointment: Made of comfrey, marshmallow, marigold, bee's wax, and oils, this is an antiseptic to be used on lesions, eczema (dry), poison ivy, soothes inflamed surfaces, abrasions, burns, hemorrhoids, for bruises and swellings. [herballegacy.com]

  As a First Aid Ointment, EMUAID ® provides symptomatic relief to minor wounds and burns, bruises, ulcerations, sunburn, razor burn, scrapes, rashes, blisters, bug bites and skin eruptions from acne, eczema or minor infection. [emuaid.com]

• Dizziness

  Get medical help right away if: You lose a lot of blood You are bleeding and feel dizzy, lightheaded, or faint Constipation, straining during bowel movements, and sitting on the toilet too long raise your risk for hemorrhoids. [nlm.nih.gov]

  Seek emergency care if you have large amounts of rectal bleeding, lightheadedness, dizziness or faintness. Causes The veins around your anus tend to stretch under pressure and may bulge or swell. [mayoclinic.org]

  […] problems persist despite trying over-the-counter hemorrhoid creams or other remedies If you're passing stools that look maroon in color or tarry in color, a sign of bleeding If you experience a large amount of rectal bleeding that is accompanied by dizziness [everydayhealth.com]

• Agitation

  This creates ionic agitation and frictional heating, leading to coagulative necrosis of tissue. Thereafter, the hemorrhoids are plicated using strong absorbable sutures. [oadoi.org]

A detailed history and thorough physical examination is enough to identify as well as grade the disease.

Laboratory tests

Laboratory tests are seldom required. An occult blood test of stool and/or stool guaiac may be performed to confirm fresh bleeding (occult blood may point towards an upper gastrointestinal bleed).

Imaging 

A Doppler ultrasound and in some rare or severe cases, a CT scan may be conducted. A sigmoidoscopy or anoscopy may be performed to see the extent of hemorrhoids. Scoping is also encouraged in such patients to exclude cancer.

Test results

Diagnosis is mainly based on history and physical examination. Test result may aid in ruling out cancer and any other lower gastrointestinal tract pathology.

Conservative management

Conservative treatment is first line of management where the patient is advised to take plenty of fluids, and a high fibre diet [8]. The use of stool softeners, particularly in patients who frequently suffer from constipation, can help in somewhat managing the condition. Non steroidal anti-inflammatory drugs (NSAIDs), corticosteroids like cortisone, and topical analgesics like lidocaine, may also help. The use of comfortable cotton undergarments may help prevent ulceration and infection.

Surgery

Radical and definitive surgical treatment is indicated in approximately one out of ten patients with hemorrhoidal disease [9]. The transanal hemorrhoidal dearterialization (THD) procedure is an effective treatment of hemorrhoidal disease [10]. Other procedure such as stapling are also used to treat hemorrhoids.

Prognosis depends upon the grade of hemorrhoids. The lower the grade of hemorrhoids, the better is the prognosis. They can be graded according to the following criterias:

Grades

• Grade I: This is the initial stage of hemorrhoids. It involves no prolapsed, just prominent vessels [6].
• Grade II: This is the second stage in which there is prolapse upon straining or bearing down but with spontaneous reduction.
• Grade III: There is prolapse but with no spontaneous reduction. It can be, however, reduced manually.
• Grade IV: Prolapse is persistent and cannot be manually reduced.

The exact cause of symptomatic hemorrhoids is unknown [2]. There may be an alteration in the muscle tissue of the internal hemorrhoid plexus which is one of the causative factors for development of hemorrhoids [3]. Venous stasis that is common during pregnancy, can be a risk factor. Constipation and forcible straining during stools can be a major predisposing factor. A combination of factors such as weakening of the vessel walls due to old age, undue straining due to long standing constipation, portal hypertension, childbirth and obesity may contribute to the development of symptomatic hemorrhoids.

Incidence

Hemorrhoids are a very frequent complaint in outpatient departments and clinics. It is common in the older age group, and almost one half of individuals older than 50 years complain of the symptoms [4].

Sex

They occur almost equally in both sexes. Some studies reveal a slightly higher frequency in females mainly because of the added stress of pregnancy and childbirth.

Age

Hemorrhoids can occur at any age but the most common age group is 45-65 years. They are rare in people younger than 30.

Race

They are common in whites, especially those belonging to a higher socioeconomic status.

An unusual change in the normal structure of hemorrhoid plexus is the pathology behind the disease [5]. Hemorrhoids consist of dilated submucosal vessels that protrude beneath the anal or rectal mucosa. Due to exposure, they easily become subject to trauma which results in inflammation and thrombosis. Superficial ulceration may also occur.

Types

Hemorrhoids, on the basis of their position, can be classified into 2 types:

• External hemorrhoids

When collateral vessels within the inferior hemorrhoidal plexus become dilated and inflamed, they are called external hemorrhoids. They are located below the anorectal line.

• Internal hemorrhoids

Dilation of the vessels of the superior hemorrhoidal plexus is termed as internal hemorrhoids. They are located within the distal rectum, along or above the anorectal line.

Hemorrhoids can be easily prevented simply be implementing a high fibre diet and drinking 8-10 glasses of water every day. Adding a higher content of whole grain and bulky fibrous food not only helps prevent hemorrhoids but also keeps the bowel in good shape. Stool softeners may also be used. By avoiding development of constipation and overdue straining during defecation, hemorrhoids can be prevented from occurring.

Hemorrhoids are dilated cushions of distal rectum and/or anal tissue that may or may not protrude out of the anal canal. They are uncomfortable and may be a source of bleeding; they can also thrombose and get inflamed, and are prone to painful ulceration [1]. Due to one or more reasons, the blood vessels present in the hemorrhoidal plexus, located in the submucosa of the distal rectum and anal canal may get congested and dilated. This dilatation of blood vessels causes pain and often, bleeding. Sometimes, the dilatation may get so severe that it may proceed to prolapse. Hemorrhoids are very common, affecting about 5% of the population.

Definition

Hemorrhoids are engorged fibrovascular cushions lining the anal canal [4]. They are swellings or dilatations of the blood vessels present inside the anal canal. They become congested and tender, due to certain causes, and result in discomfort during sitting and bowel movements and are prone to bleed.

Cause

Hemorrhoids are commonly due to long lasting constipation resulting in straining during defection. Other causes include pregnancy and childbirth, portal hypertension and obesity.

Symptoms

Symptoms include sharp pain during bowel movements accompanied with fresh, bright red coloured blood. There may also be palpable, tender lumps within the anus, itching around the perineum, pelvic pain and sometimes a red coloured lump might appear to be falling or coming out of the anus during straining.

Treatment

Conservative treatment includes dietery modifications, topical analgesics and stool softeners. Surgically, transanal hemorrhoidal dearterialization (THD) is a safe procedure and is, at present, one of the most effective treatments of hemorrhoidal disease [10].

1. Wald A, Bharucha AE, Cosman BC, et al. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. Aug 2014;109(8):1141-57; (Quiz) 10
2. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology. Feb 1990;98(2):380-6.
3. Raahave D, Jepsen LV, Pedersen IK. Primary and repeated stapled hemorrhoidopexy for prolapsing hemorrhoids: follow-up to five years. Dis Colon Rectum. Mar 2008;51(3):334-41.
4. Perera N, Liolitsa D, Iype S, Croxford A, Yassin M, Lang P, et al. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev. Aug 15 2012;8:CD004322.
5. Faucheron JL, Gangner Y. Doppler-guided hemorrhoidal artery ligation for the treatment of symptomatic hemorrhoids: early and three-year follow-up results in 100 consecutive patients. Dis Colon Rectum. Jun 2008;51(6):945-9.
6. Senapati A, Nicholls RJ. A randomised trial to compare the results of injection sclerotherapy with a bulk laxative alone in the treatment of bleeding haemorrhoids. Int J Colorectal Dis. Jun 1988;3(2):124-6.
7. Ho YH, Cheong WK, Tsang C, Ho J, Eu KW, Tang CL, et al. Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum. Dec 2000;43(12):1666-75.
8. Bove A, Bongarzoni G, Palone G, Chiarini S, Calisesi EM, Corbellini L. Effective treatment of haemorrhoids: early complication and late results after 150 consecutive stapled haemorrhoidectomies. Ann Ital Chir. Jul-Aug 2009;80(4):299-303.
9. Perrotti P, Antropoli C, Molino D, De Stefano G, Antropoli M. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. Mar 2001;44(3):405-9.
10. Gorfine SR. Treatment of benign anal disease with topical nitroglycerin. Dis Colon Rectum. May 1995;38(5):453-6; discussion 456-7.