Hemorrhoids (AmE), haemorrhoids (BrE), emerods, or piles are swelling and

inflammation of veins in the rectum and anus. The anatomical term "hemorrhoids"
technically refers to "'Cushions of tissue filled with blood vessels at the junction of the
rectum and the anus."[1] However, the term is popularly used to refer to varicosities of the
hemorrhoid tissue. Perianal hematoma are sometimes misdiagnosed and mislabeled as
hemorrhoids, when in fact they have different causes and treatments.[2]

[edit] Causes
Sitting for long periods of time can start the hemorrhoidic process.

Increased straining during bowel movements caused by constipation or diarrhea may lead
to hemorrhoids.[3] It is thus a common condition due to constipation caused by water
retention in women experiencing premenstrual syndrome or menstruation.

Hypertension, particularly portal hypertension, can also cause hemorrhoids because of the
connections between the portal vein and the vena cava which occur in the rectal wall—
known as portocaval anastomoses.[4]

Obesity can be a factor by increasing rectal vein pressure. Poor muscle tone or poor
posture can result in too much pressure on the rectal veins.

Pregnancy may lead to hypertension and increase strain during bowel movements, so
hemorrhoids are often associated with pregnancy.[citation needed]

Cigarette smoking during bowel movements, may worsen hemorrhoid, may lead to
severe internal bleeding of veins inside rectum area. Both can cause diarrhea. Note that
caffeine ingestion increases blood pressure transiently, but is not thought to cause chronic
hypertension.

[edit] Symptoms

Many anorectal problems, including fissures, fistulae, abscesses, anal melanoma or

irritation and itching, also called pruritus ani, have similar symptoms and are incorrectly
referred to as hemorrhoids.

Hemorrhoids are usually not dangerous or life threatening. In most cases, hemorrhoidal
symptoms will go away within a few days.

Although many people have hemorrhoids, and hemorroidial radiation, not all experience
symptoms. The most common symptom of internal hemorrhoidial radiation is bright red
blood covering the feces (hematochezia), on toilet paper, and/or in the toilet bowl.
However, an internal hemorrhoid may protrude through the anus outside the body,
becoming irritated and painful. This is known as a protruding hemorrhoid.
Symptoms of external hemorrhoids may include painful swelling or a hard lump around
the anus that results when a blood clot forms. This condition is known as a thrombosed
external hemorrhoid.

In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation
with bleeding and/or itching, which may produce a vicious circle of symptoms. Draining
anal mucus, produced by the dentate line may also cause itching.

[edit] Food

Insufficient liquid can cause a hard stool, or even chronic constipation, which can lead to
hemorrhoidal radiation. An excess of lactic acid in the stool, a product of excessive
consumption of dairy products, such as yogurt, can cause radiation; reducing such
consumption can bring relief.[citation needed] Vitamin E deficiency is also a common cause.
[citation needed]
Eating spicy food does not cause hemorrhoids, though spicy foods may
aggravate the condition.[citation needed]

[edit] Types of hemorrhoids

Direct view of hemorrhoid seen on sigmoidoscopy

• (I84.3-I84.5) External hemorrhoids are those that occur outside the anal verge (the
distal end of the anal canal). Specifically they are varicosities of the veins
draining the territory of the inferior rectal arteries, which are branches of the
pudendal artery. They are sometimes painful, and can be accompanied by
swelling and irritation. Itching, although often thought to be a symptom of
external hemorrhoids, is more commonly due to skin irritation.
o (I84.3) External hemorrhoids are prone to thrombosis: if the vein ruptures
and/or a blood clot develops, the hemorrhoid becomes a thrombosed
hemorrhoid.[5]
• (I84.0-I84.2) Internal hemorrhoids are those that occur inside the rectum.
Specifically they are varicosities of veins draining the territory of branches of the
superior rectal arteries. As this area lacks pain receptors, internal hemorrhoids are
usually not painful and most people are not aware that they have them. Internal
hemorrhoids, however, may bleed when irritated.
• (I84.1) Untreated internal hemorrhoids can lead to two severe forms of
hemorrhoids: prolapsed and strangulated hemorrhoids:
 o Prolapsed hemorrhoids are internal hemorrhoids that are so distended that
they are pushed outside the anus.
o If the anal sphincter muscle goes into spasm and traps a prolapsed
hemorrhoid outside the anal opening, the supply of blood is cut off, and
the hemorrhoid becomes a strangulated hemorrhoid.

[edit] By degree of prolapse

The most common grading system was developed by Banov:[6][7]

• Grading of Internal Hemorrhoids

o Grade I: The hemorrhoids do not prolapse.
o Grade II: The hemorrhoids prolapse upon defecation but spontaneously
reduce.
o Grade III: The hemorrhoids prolapse upon defecation, but must be
manually reduced.
o Grade IV: The hemorrhoids are prolapsed and cannot be manually
reduced.

[edit] Prevention
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Prevention of hemorrhoids includes drinking more fluids, eating more dietary fiber (such
as fruits, vegetables and cereals high in fiber), exercising, practicing better posture, and
reducing bowel movement strain and time. Wearing tight clothing and underwear may
also contribute to irritation and poor muscle tone in the region and promote hemorrhoid
development.

Women who notice they have painful stools around the time of menstruation would be
well-advised to begin taking extra dietary fiber and fluids a couple days prior to that time.

Fluids emitted by the intestinal tract may contain irritants that may increase the fissures
associated with hemorrhoids. Washing the anus with cool water and soap may reduce the
swelling and increase blood supply for quicker healing and may remove irritating fluid.

Kegel exercises for the pelvic floor may also prove helpful.

Many people do not get a sufficient supply of dietary fiber (20 to 25 grams daily) and
small changes in a person's daily diet can help tremendously in both prevention and
treatment of hemorrhoids.

[edit] Use of squat toilets

Based on their very low incidence in the developing world, where people squat for bodily
functions, hemorrhoids have been attributed to the use of the "sitting" toilet.[8][9] Dr. Berko
Sikirov published a study in 1987 testing this hypothesis by having hemorrhoid sufferers
convert to squat toilets.[10] Eighteen of the 20 patients were completely relieved of their
symptoms (pain and bleeding) with no recurrence, even 30 months after completion of
the study. This chart summarizes the results. This study was undertaken in a very small
number of people, when compared to the numbers involved in recognized high-quality
trials. Therefore, the results, while highly suggestive, cannot be assumed to provide a
firm conclusion.

No follow-up studies have ever been published. The American Society of Colon & Rectal
Surgeons is silent regarding the therapeutic value of squatting.

[edit] Examination

Endoscopic image of internal hemorrhoids seen on retroflexion of the flexible

sigmoidoscope at the ano-rectal junction

After visual examination of the anus and surrounding area for external or prolapsed
hemorrhoids, a doctor may conduct a digital examination. In addition to probing for
hemorrhoidal bulges, a doctor may also look for indications of rectal tumor or polyp,
enlarged prostate and abscesses.

Visual confirmation of hemorrhoids can be done by doing an anoscopy, using a medical

device called an anoscope. This device is basically a hollow tube with a light attached at
one end that allows the doctor to see the internal hemorrhoids, as well as polyps in the
rectum.

If warranted, more detailed examinations, such as sigmoidoscopy and colonoscopy can

be performed. In sigmoidoscopy, the last 60 cm of the colon and rectum are examined
whereas in colonoscopy the entire large bowel (colon) is examined.

A pathologist will look for dilated vascular spaces which exhibit thrombosis and
recanalization.

[edit] Treatments
Treatments for hemorrhoids vary in their cost, risk, and effectiveness. Different cultures
and individuals approach treatment differently. Some of the treatments used are listed
here in increasing order of intrusiveness and cost.

For many people, hemorrhoids are mild and temporary conditions that heal spontaneously
or by the same measures recommended for prevention. There is no medicine that will
cure hemorrhoids but local treatments such as warm sitz baths, using a bidet, extendable
showerhead, cold compress, or topical analgesic (such as Nupercainal), can also provide
temporary relief.

Especially in the case of external hemorrhoids with a visible lump of small size, the
condition can be improved with warm bath causing the vessels around the rectal region to
be relaxed. Consistent use of medicated creams during the early stages of a hemorrhoid
flare-up will also provide relief and may stave off further development and irritation.
However, creams containing steroid preparations weaken the skin and may contribute to
further flare-ups. Keep the area clean and dry, with some lubrication provided by
hemorrhoidal creams or a lubricant. Ointment or suppositories such as Proctosedyl[11][12]
and Faktu[13] can also relieve the symptoms.

[edit] Surgical and non-medicinal treatments

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Some people require the following medical treatments for chronic or severe hemorrhoids:

• Rubber band ligation

Sometimes called Baron ligation. Elastic bands are applied onto an internal
hemorrhoid to cut off its blood supply.[14] Within several days, the withered
hemorrhoid is sloughed off during normal bowel movement.
• Hemorrhoidolysis/Galvanic Electrotherapy
Desiccation of the hemorrhoid by electrical current.
• Sclerotherapy (injection therapy)
Sclerosant or hardening agent is injected into hemorrhoids. This causes the vein
walls to collapse and the hemorrhoids to shrivel up.
• Cryosurgery
A frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues.[15] Rarely used
anymore because of side effects.
• Laser, infrared or BICAP coagulation
Laser, infrared beam, or electricity is used to cauterize the affected tissues. Lasers
are now much less popular. Infrared coagulation has been studied in comparison
with RBL and found to be as effective in hemorrhoids up to grade III. These are
the most readily available non-surgical procedures in the US.
• Hemorrhoidectomy
A true surgical procedure to excise and remove hemorrhoids. Has possible
 correlation with incontinence issues later in life; in addition, many patients
complain that pain during recovery is severe. For this reason is often now
recommended only for severe (grade IV) hemorrhoids.
• Stapled Hemorrhoidectomy
Also called the procedure for prolapse and hemorrhoids, it is designed to resect
soft tissue proximal to the dentate line, which disrupts the blood flow to the
hemorrhoids. It is generally less painful than complete removal of hemorrhoids
and also allows for faster recovery times. It's meant for hemorrhoids that fall out
or bleed and is not helpful for painful outside conditions.
• Enema
This practice is used to clean the rectum. While it is a simple procedure, it can be
complicated by hemorrhoids, so in such cases, it should be done by a doctor. In an
enema, water is injected into the rectum and then flushed out, cleaning the area.
• Doppler Guided Hemorrhoidal Artery Ligation
The only evidence-based surgery for all grades of hemorrhoids. It does not
involve cutting tissues or even a stay at the hospital; patients are usually back to
work on the same day. It is the best treatment for bleeding piles, as the bleeding
stops immediately. [16]
• HAL-RAR[1]
To date, Doppler Guided Hemorrhoidal Artery Ligation was indicated in
management of Grade II & Grade III Hemorrhoids but with the availability of
HAL Recto Anal Repair Management of prolapsing hemorrhoids without excision
is also possible.
• Transanal Hemorrhoidal Dearterialization (THD-HP)
THD-HP is a minimally invasive treatment for hemorrhoids and hemorrhoidal
prolapse. THD uses an ultrasound doppler to accurately locate the arterial blood
inflow. With simple suture, these arteries are “tied off” and the prolapsed tissue is
sutured back to anatomical position without excision of tissue. THD is performed
above the nerve bundles, or dentate line. Because of this, there is very little pain.
THD is typically performed in an out-patient setting and return to normal
activities is within a few days.
• Procedure for Prolapse and Hemorrhoids
(or PPH) Using a hemorrhoidal circular stapler device, the procedure for prolapse
and hemorrhoids procedure essentially "lifts up," or repositions the mucosa, or
anal canal tissue, and reduces blood flow to the internal hemorrhoids. These
internal hemorrhoids then typically shrink within four to six weeks after the
procedure. The PPH procedure results in less pain than traditional
hemorrhoidectomy procedures because it is performed above the area where a
person would feel pain, or dentate line inside the anal canal. The advantage is that
this hemorrhoid treatment method affects few nerve endings, while traditional
hemorrhoidectomy procedures are performed below the dentate line, affecting
many sensitive nerve endings.

• Radiofrequency Coagulation

[edit] Natural treatments

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Please help improve this article by adding reliable references. Unsourced material may be
challenged and removed. (May 2009)

Some people claim to have successfully applied natural procedures for treatment or
reversal of chronic conditions. These procedures largely echo the prevention measures.
However, self-care measures, including herbal or "natural" remedies, should not be
undertaken without medical consent to avoid possible drug interactions. They include:

• Topical application of natural astringents and soothing agents, such as Witch

hazel (astringent), Cranesbill, Aloe vera, and honey.
• Eating fiber-rich bulking agents such as plantain and Psyllium seed husks to help
create a softer stool that is easier to pass, to lessen the irritation of existing
hemorrhoids.
• Using the squatting position for bowel movements.[17]
• For sufferers of hemorrhoids caused by poor vein circulation (coupled with
varicose veins in lower extremities and/or varicocele), sleeping overnight with
raised legs helps reduce or completely eliminate especially external hemorrhoids
as well as taking a dietary supplement like hem-eez, which has shown to increase
circulation and help to restore flexibility back to the vessel walls.
• Placing an ice pack to an external hemorrhoid should relieve itching and swelling.
Leave the ice pack on the hemorrhoid for 15 to 20 minutes.

The combination of internal and external remedies is particularly recommended, e.g.,

Witch-hazel suppositories combined with frequent cups of strong chamomile tea.[18]

Dietary supplements can help treat and prevent many complications of hemorrhoids, and
natural botanicals such as Butchers Broom, Horse-chestnut, Hem-eez and bioflavonoids
can be an effective addition to hemorrhoid treatment.[19]

Butcher's Broom extract, or Ruscus aculeatus, contains ruscogenins that have anti-
inflammatory and vasoconstrictor effects that help tighten and strengthen veins. Butcher's
Broom has traditionally been used to treat venous problems including hemorrhoids and
varicose veins.[20][21][22]

Horse-chestnut extract, or Aesculus hippocastanum, contains a saponin known as aescin,

that has anti-inflammatory, anti-edema, and venotonic actions. Aescin improves tone in
vein walls, thereby strengthening the support structure of the vein. Double blind studies
have shown that supplementation with Horse-chestnut helps relieve the pain and swelling
associated with chronic venous insufficiency.[23][24]

Bilberry extract, or Vaccinium myrtillus, is an anthocyanoside bioflavonoid.

Supplementation with this potent flavonoid protects and maintains venous strength and
function.[20][25]

[edit] Diseases with similar symptoms

Symptoms associated with rectal cancer, anal fissure, anal abscess, anal fistula, perianal
hematoma, and other diseases may be similar to those produced by hemorrhoids and may
be reduced by the topical analgesic methods described above. For this reason, it is a good
idea to consult with a physician when these symptoms are encountered, particularly for
the first time, and periodically should the problem continue. In the US, colonoscopy is
recommended as a general diagnostic for those over age 50 (40 with family history of
bowel cancers).

[edit] Hemorrhoids in popular culture

• George Brett of the Kansas City Royals famously had to leave game 2 of the 1980
World Series due to extreme pain from hemorrhoids, but returned in game 3
following a procedure to relieve the pain. In 1981 he missed 2 weeks of spring
training having the hemorrhoids removed. [26]
• In the 'South Park' episode 'Cartmanland', when Cartman inherits $1,000,000 from
his grandmother, Kyle gets a hemorrhoid the next day. Later, after he and Stan try
to break into Cartmanland, Kyle bursts his hemorrhoid on the fence and ends up
in the hospital. The more successful Cartman got with Cartmanland, the worse
Kyle felt, causing him to renounce his beliefs in God and nearly die. It disappears
once Cartman went bankrupt.
• Michael Scott, a main character in NBC's 'The Office,' proclaims that he has
hemorrhoids when he is alone in the woods.
• American film director Kevin Smith mentions that he frequently gets hemorrhoids
during the third installment of his An Evening With Kevin Smith question and
answer series.