History of Hemorrhoids

Hemorrhoids (US English) or haemorrhoids are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become pathological or piles when swollen or inflamed. At this point the condition is technically known as hemorrhoidal disease.

The signs and symptoms of hemorrhoids depend on the type present. Internal hemorrhoids usually present with painless rectal 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. 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 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 lives. Outcomes are usually good.

Internal and external hemorrhoids may present differently; however, many people may have a combination of the two. Bleeding significant enough to cause anemia is rare, and life-threatening bleeding is even more uncommon.  Many people feel embarrassed when facing the problem and frequently seek medical care only when the case is advanced.

External

If not thrombosed, external hemorrhoids may cause few problems. However, when thrombosed, hemorrhoids may be very painful. Nevertheless, this pain typically resolves in two to three days. The swelling may, however, take a few weeks to disappear. A skin tag may remain after healing. If hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin, and thus itchiness around the anus.

Internal

Internal hemorrhoids usually present with painless, bright red rectal bleeding during or following a bowel movement. The blood typically covers the stool (a condition known as hematochezia), is on the toilet paper, or drips into the toilet bowl. The stool itself is usually normally coloured. Other symptoms may include mucous discharge, a perianal mass if they prolapse through the anus, itchiness, and fecal incontinence. Internal hemorrhoids are usually only painful if they become thrombosed or necrotic.

Causes

The exact cause of symptomatic hemorrhoids is unknown. A number of factors are believed to play a role, including irregular bowel habits (constipation or diarrhea), lack of exercise, nutritional factors (low-fiber diets), increased intra-abdominal pressure (prolonged straining, ascites, an intra-abdominal mass, or pregnancy), genetics, an absence of valves within the hemorrhoidal veins, and aging. Other factors believed to increase risk include obesity, prolonged sitting, a chronic cough, and pelvic floor dysfunction. Evidence for these associations, however, is poor.

During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. The birth of the baby also leads to increased intra-abdominal pressures. Pregnant women rarely need surgical treatment, as symptoms usually resolve after delivery.

Pathophysiology

Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes. There are three main cushions present in the normal anal canal. These are located classically at left lateral, right anterior, and right posterior positions. They are composed of neither arteries nor veins, but blood vessels called sinusoids, connective tissue, and smooth muscle. Sinusoids do not have muscle tissue in their walls, as veins do. This set of blood vessels is known as the hemorrhoidal plexus.

Hemorrhoid cushions are important for continence. They contribute to 15–20% of anal closure pressure at rest and protect the internal and external anal sphincter muscles during the passage of stool. When a person bears down, the intra-abdominal pressure grows, and hemorrhoid cushions increase in size helping to maintain anal closure. Hemorrhoid symptoms are believed to result when these vascular structures slide downwards or when venous pressure is excessively increased. Increased internal and external anal sphincter pressure may also be involved in hemorrhoid symptoms. Two types of hemorrhoids occur: internals from the superior hemorrhoidal plexus and externals from the inferior hemorrhoidal plexus. The dentate line divides the two regions.