HEMORRHOIDS

21. What are hemorrhoidal tissues, and what are their normal functions?

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Hemorrhoids are cushions of vascular tissue that contribute to anal continence and protect the sphincter mechanism during defecation. Hemorrhoids are not veins, but sinusoids. Bleeding originates from presinusoidal arterioles, thus explaining the bright red arterial color.

22. What are the most common causes of pathologic hemorrhoids?

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Constipation, prolonged straining, pregnancy, and internal sphincter dysfunction.

23. What is the most important difference between internal and external hemorrhoids?

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Whereas internal hemorrhoids are located above the dentate line with visceral innervation, external hemorrhoids are located below the dentate line with somatic innervation. Ablation of internal hemorrhoids causes a pressure sensation with an urge to defecate, but a similar approach to external hemorrhoids causes excruciating pain.

24. What are the most common complaints associated with pathologic internal hemorrhoids?

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Bleeding, mucus discharge, and prolapsing tissue.

25. What are the most common complaints associated with external hemorrhoids?

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Pain, inflammation, thrombosis, and difficulty with anal hygiene.

26. Are there any treatment options for symptomatic internal hemorrhoids based on identifiable physical characteristics?

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Yes. Treatment is based on the degree of prolapse:

Grade 1: None
Grade 2: Spontaneous reduction
Grade 3: Manual reduction
Grade 4: Unreducible

27. How are patients with symptomatic grades 2 and 3 and occasionally grade 4 internal hemorrhoids treated?

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Diet and stool bulking, rubber band ligation, injection sclerotherapy, cryotherapy, infrared photocoagulation, anal dilatation, or electrocautery.

28. What is the last-resort treatment for recalcitrant symptomatic internal hemorrhoids or combined internal and external hemorrhoids?

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Operative hemorrhoidectomy.