Hemorrhoids
Hemorrhoids are one of the most frequent anorectal disorders encountered in the office setting and are responsible for considerable patient suffering and disability. Hemorrhoids that become symptomatic are initially treated conservatively with dietary cha
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Key Concepts • The classification system of hemorrhoidal disease is based on the degree of clinical prolapse seen on the physical examination. • Medical therapy for hemorrhoidal symptoms should be the initial treatment recommendation and can include dietary changes, increased water intake, fiber supplementations, and ointment therapy. • Office-based procedures are offered mainly for internal hemorrhoidal disease with the most common procedure being rubber band ligation. • Injection sclerotherapy may be performed on an anticoagulated patient due to the fibrotic reaction with almost no increased risk of bleeding. • Excisional hemorrhoidectomy is the gold standard by which all surgical procedures are compared. • Postoperative bleeding can occur at one of two different times, right after the procedure itself and delayed hemorrhage occurring 7–10 days post procedure. • Urgent hemorrhoid surgery is usually reserved for the patient with strangulated, incarcerated, gangrenous hemorrhoids. Hemorrhoids are one of the most common ailments that will be seen by a colon and rectal surgeon. While hemorrhoids can present in many different ways, there are a number of different conditions that are mistaken by patients and practitioners alike as “hemorrhoids.”
Anatomy Hemorrhoids are a normal part of the anal canal. Our understanding of hemorrhoid anatomy has not changed substantially since 1975 when Thomson published his master’s Electronic supplementary material: The online version of this chapter (doi:10.1007/978-3-319-25970-3_12) contains supplementary material, which is available to authorized users.
thesis based on anatomic and radiologic studies and first used the term “vascular cushions” [1]. Per Thomson, the submucosa does not form a continuous ring of thickened tissue but instead is a discontinuous series of cushions. Anatomically the three main cushions are located in the left lateral, right anterior, and right posterior positions. Each of these thicker layers has a submucosa filled with blood vessels and muscle fibers. The muscle fibers arise from the internal sphincter and from the conjoined longitudinal muscle. These muscle fibers are thought to be important in maintaining the integrity of the hemorrhoid, and it is the breakdown of this tissue that can contribute to the hemorrhoids becoming symptomatic. The arterial blood supply to hemorrhoids is primarily from the terminal branches of the superior hemorrhoidal artery; branches of the middle hemorrhoidal artery also contribute. Venous outflow is from the superior, middle, and inferior hemorrhoidal veins (Figure 12-1) [2].
Etiology There are numerous possible reasons why hemorrhoids become symptomatic. Dietary patterns, behavioral factors, anything that can cause excessive straining, and sphincter dysfunction are among the most common reasons. Thompson’s vascular cushion theory states that normal hemorrhoidal tissue represents discrete masses of submucosa. During straining, the vascular cushions can become engorged and possibly prevent the escape of fecal material or gas. With
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