GE 2004;126:1463; Prim Care 1999;26:35

Epidem: The prevalence of hemorrhoids is 80-90% in U.S. adults, with equal prevalence in men and women (Dis Colon Rectum 1983;26:435). Symptomatic hemorrhoids are unusual before age 20 yr, peak at age 45-65 yr, and are associated with higher socioeconomic status (GE 1990;98:380). Pregnancy is a risk factor.

Pathophys: Hemorrhoids are classified as internal or external based on the anatomic location from which they originate. Two areas are important to recognize. The anal verge is the most distal portion of the anal canal. About 2-3 cm above the verge is the dentate or pectinate line, the junction of anal and rectal mucosa. Hemorrhoids are pathologic dilatations of the normal vascular beds. Hemorrhoids are internal if they originate from the vascular bed above the dentate line, and they are external if they originate below the dentate line in the bed close to the anal verge. The point of origination, notthe distal extent of the hemorrhoid, defines it as internal or external. Internal hemorrhoids are covered by rectal mucosa and have no somatic sensation, while external hemorrhoids are covered by anoderm and have the somatic sensation of skin. Internal hemorrhoids are graded based on the degree of prolapse (grade I = no prolapse, grade II = spontaneous reduction, grade III = manual reduction, grade IV = cannot be reduced). The pathogenesis of hemorrhoids is notwell understood, though straining is thought to be of importance in disrupting the vascular beds. Both constipation and diarrhea are conditions associated with hemorrhoids (Dis Colon Rectum 1998;41:1534).

Sx: Internal hemorrhoids cause painless bleeding or prolapse. Blood is usually bright red and is seen on toilet tissue or around stool, or it may drip into the toilet if there is prolapse. Prolapsed hemorrhoids may result in a discharge on underwear. Painful thrombosis of internal hemorrhoids is uncommon. External hemorrhoids begin as small skin tags, cause problems with hygiene, cause perianal irritation, and can acutely thrombose, causing acute, severe pain.

Si: External hemorrhoids are visible; internal hemorrhoids are not unless prolapsed. Most internal hemorrhoids are notpalpable, and anoscopy is mandatory to establish their presence or absence.

Crs: Sx are usually mild and intermittent. Only a minority of pts require interventions beyond topical measures or develop complications such as thrombosis or permanent prolapse.

Cmplc: Thrombosis, presenting as acute pain.

Diff Dx: The presence of hemorrhoids is easily established and the diagnostic pitfall is usually in determining if hemorrhoids are the cause of a given sx. The differential includes other causes of rectal bleeding such as fissure, polyp, cancer, and IBD, and other causes of perianal discomfort such as abscess or fistula. A fissure should be suspected if there is pain and spasm on exam. Hemorrhoids should notbe accepted as a cause of rectal bleeding without further evaluation (detailed on p 24).

Lab: Usually notindicated except in substantial, chronic bleeding.

Endoscopy: Anoscopy is easy to perform and very informative. Hemorrhoids are better assessed with an anoscope than a colonoscope, though the latter is more fun to use. At anoscopy, the dentate line is identified, the distal rectal mucosa is inspected, and hemorrhoids are identified as reddish-bluish protrusions into the lumen. Anoscopy also allows for the evaluation of fissures.

Rx: A high-fiber diet to keep stools soft is usually all that is needed for sx of painless bleeding from grade I or II hemorrhoids. Some pts experience local problems with itching or burning secondary to difficult hygiene or edema associated with the hemorrhoids. This often improves with local measures such as diaper wipes, witch hazel pads, and sitz baths. Hydrocortisone creams with or without an anesthetic are popular adjunctive rx without proven efficacy.

Rubber band ligation is effective for reducible hemorrhoids. The hemorrhoid is dragged into a hollow chamber and rubber bands deployed off the chamber around the base of the hemorrhoid. Bands are placed at least 5 mm above the dentate line to avoid pain. One hemorrhoid is done at a time, with a 2- to 4-wk wait between treatments. About 5-10% of pts experience achy pain and some bleeding, and rarely, pelvic sepsis is seen. Injection sclerotherapy, infrared coagulation, electrocoagulation, and laser treatment have all been used successfully. Cryotherapy should be avoided because of a high complication rate. Rubber band ligation is cheap and has the highest long-term efficacy, but it has a higher incidence of postoperative pain than infrared coagulation or injection sclerotherapy (Am J Gastro 1992;87:1600). Surgical hemorrhoidectomy is done for pts with prolapse (grades III and IV), pts with concomitant external hemorrhoids, and pts in which other methods fail. Thrombosed external hemorrhoids present with a visibly swollen, often painful mass that is filled with a firm clot. Pts presenting with acute sx should be treated with prompt evacuation of the clot for pain relief.

Brit J Surg 1996;83:1335

Epidem: A common complaint in young adults, affecting men and women equally.

Pathophys: (Scand J Gastroenterol Suppl 1996;218:78) An anal fissure is a crack in the skin of the anal canal. Acute fissures are quite superficial and are usually the result of traumatic laceration from hard, dry stool. A minority of acute fissures fail to heal and become deep, with indurated edges. Chronic fissures occur in the posterior midline in 90% of affected males and
75% of affected females. Most of the remainder occur in the anterior midline. One hypothesis is that elevated resting tone of the internal anal sphincter results in poor perfusion of the skin in the posterior midline and the failure of the fissure to heal.

Sx: The typical sx are pain with or after BMs, blood on tissue or around BMs, and itch.

Si: Acute fissures are superficial lacerations and often can be seen by parting the buttocks. Chronic fissures have heaped-up edges, a fibrotic-looking base, and frequently have a midline skin tag at the end of the fissure. A rectal or anoscopic exam can be difficult because of associated spasm.

Crs: Most fissures are acute and heal spontaneously. A minority become chronic (sx greater than 6-8 wk) and may have cycles of healing and recurrence.

Diff Dx: Fissures can be secondary to Crohn’s, syphilis, TB, HIV, leukemia, IBD, or anal cancer. Consider these diagnoses, especially if the fissure is notmidline.

Endoscopy: Anal fissures are better seen with an anoscope than a colonoscope. Topical lidocaine can be helpful, but sometimes pain and spasm are too great to proceed without general anesthesia or deep sedation.

Rx: Most acute fissures are treated by making the stool softer (high-fiber diet and fiber supplements or stool softeners such as sodium ducosate 100 mg po tid) and with topical hydrocortisone preparations with an anesthetic. Witch hazel pads, diaper wipes, or sitz baths may be soothing. Chronic fissures are treated by methods that lower anal sphincter pressure and presumably restore blood flow to the skin of the posterior midline. Forceful anal dilatation is effective but associated with high rates of fecal incontinence. Lateral internal sphincterotomy is the most common current surgical approach. In this procedure, the internal anal sphincter is cut in a lateral position (rather than in the posterior midline). The major problem with lateral internal sphincterotomy is incontinence, with rates as high as 35% reported (Am J Surg 1996;171:512). Modifications such as a sphincterotomy tailored to the length of the fissure may reduce that rate (Dis Colon Rectum 1997;40:1439). The trend in therapy is to use drugs to lower sphincter pressure rather than to cut the sphincter. More than 80 trials of rx to reduce sphincter pressure have been reported (Am J Gastro 2007;102:1312). Topical nitrates dilate the anal sphincter and result in healing of fissures in 40-80% of pts (reviewed in GE 2003;124:235). Glyceryl trinitrate 0.2% is applied bid to the anal canal for 6 wk and is usually well tolerated, though headache is a common problem. This is a much lower concentration of nitroglycerin than is used in cardiac disease, and this concentration is notcommercially available in the U.S., but can be made by a compounding pharmacy. Topical diltiazem gel (2%) is effective and well tolerated but notavailable commercially in the U.S. Botulinum toxin injected into the sphincter is more effective than placebo (Nejm 1998;338:217) and topical nitroglycerin (Br J Surg 2007;94:162) but is expensive and invasive compared with nitrates. A reasonable approach would be to offer nitrates or diltiazem topically as first-line treatment. Failures can be offered botulinum injections, followed by lateral sphincterotomy if medical rx fails.