29 Haziran 2011 Çarşamba

Hemorrhoids Pictures








What causes hemorrhoids?

It is not known why hemorrhoids enlarge. There are several theories about the cause, including inadequate intake of fiber, prolonged sitting on the toilet, and chronic straining to have a bowel movement (constipation). None of these theories has strong experimental support. Pregnancy is a clear cause of enlarged hemorrhoids though, again, the reason is not clear. Tumors in the pelvis also cause enlargement of hemorrhoids by pressing on veins draining upwards from the anal canal.

One theory proposes that it is the shearing (pulling) force of stool, particularly hard stool, passing through the anal canal that drags the hemorrhoidal cushions downward. Another theory suggests that with age or an aggravating condition, the supporting tissue that is responsible for anchoring the hemorrhoids to the underlying muscle of the anal canal deteriorates. With time, the hemorrhoidal tissue loses its mooring and slides down into the anal canal.

One physiological fact that is known about enlarged hemorrhoids that may be relevant to understanding why they form is that the pressure is elevated in the anal sphincter, the muscle that surrounds the anal canal and the hemorrhoids. The anal sphincter is the muscle that allows us to control our bowel movements. It is not known, however, if this elevated pressure precedes the development of enlarged hemorrhoids or is the result of the hemorrhoids. Perhaps during bowel movements, increased force is required to force stool through the tighter sphincter. The increased shearing force applied to the hemorrhoids by the passing stool may drag the hemorrhoids downward and enlarge them.

What are the symptoms of hemorrhoids?

There are two types of nerves in the anal canal, visceral nerves (above the dentate line) and somatic nerves (below the dentate line). The somatic (skin) nerves are like the nerves of the skin and are capable of sensing pain. The visceral nerves are like the nerves of the intestines and do not sense pain, only pressure. Therefore, internal hemorrhoids, which are above the dentate line, usually are painless.

As the anal cushion of an internal hemorrhoid continues to enlarge, it bulges into the anal canal. It may even pull down a portion of the lining of the rectum above, lose its normal anchoring, and protrude from the anus. This condition is referred to as a prolapsing internal hemorrhoid. In the anal canal, the hemorrhoid is exposed to the trauma of passing stool, particularly hard stools associated with constipation. The trauma can cause bleeding and sometimes pain when stool passes. The rectal lining that has been pulled down secretes mucus and moistens the anus and the surrounding skin. Stool also can leak onto the anal skin. The presence of stool and constant moisture can lead to anal itchiness (pruritus ani), though itchiness is not a common symptom of hemorrhoids. The prolapsing hemorrhoid usually returns into the anal canal or rectum on its own or can be pushed back inside with a finger, but it prolapses again with the next bowel movement.

Less commonly, the hemorrhoid protrudes from the anus and cannot be pushed back inside, a condition referred to as incarceration of the hemorrhoid. Incarcerated hemorrhoids can have their supply of blood shut off by the squeezing pressure of the anal sphincter, and the blood vessels and cushions can die, a condition referred to as gangrene. Gangrene requires medical treatment.

For convenience in describing the severity of internal hemorrhoids, many physicians use a grading system:

First-degree hemorrhoids: Hemorrhoids that bleed but do not prolapse.

Second-degree hemorrhoids: Hemorrhoids that prolapse and retract on their own (with or without bleeding).

Third-degree hemorrhoids: Hemorrhoids that prolapse but must be pushed back in by a finger.

Fourth-degree hemorrhoids: Hemorrhoids that prolapse and cannot be pushed back in.

Fourth-degree hemorrhoids also include hemorrhoids that are thrombosed (containing blood clots) or that pull much of the lining of the rectum through the anus.

In general, the symptoms of external hemorrhoids are different than the symptoms of internal hemorrhoids.

External hemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal hemorrhoids. This is perhaps, because they are low in the anal canal and have little effect on the function of the anus, particularly the anal sphincter. External hemorrhoids can cause problems, however, when blood clots inside them. This is referred to as thrombosis. Thrombosis of an external hemorrhoid causes an anal lump that is very painful (because the area is supplied by somatic nerves) and often requires medical attention. The thrombosed hemorrhoid may heal with scarring and leave a tag of skin protruding from the anus. Occasionally, the tag is large, which can make anal hygiene (cleaning) difficult or irritate the anus.

Hemorrhoid surgery videos

Hemorrhoid Surgery Videos

Hemorrhoid Overview

Hemorrhoids are enlarged veins located in the lower part of the rectum and the anus. They become swollen because of increased pressure within them, usually due to straining at stools and during pregnancy because of the pressure of the enlarged uterus.

Internal hemorrhoids are located in the inside lining of the rectum and cannot be felt. They are usually painless and make their presence known by causing bleeding with a bowel movement. Internal hemorrhoids can prolapsed or protrude through the anus.

External hemorrhoids are located underneath the skin that surrounds the anus. They can be felt when they swell and may cause itching or pain with a bowel movement, as well as bleeding. A thrombosed external hemorrhoid occurs when blood within the
 vein clots, and can cause significant pain.

Notable cases

Hall-of-Fame baseball player George Brett was famously removed from a game in the 1980 World Series due to hemorrhoid pain. After undergoing minor surgery, Brett returned to play in the next game, quipping "...my problems are all behind me." Brett underwent further hemorrhoid surgery the following spring.

Etymology

First attested in English 1398, the word hemmorrhoid derives from the Old French "emorroides", from Latin "hæmorrhoida -ae", in turn from the Greek "αἱμορροΐς" (haimorrhois), "liable to discharge blood", from "αἷμα" (haima), "blood" + "ῥόος" (rhoos), "stream, flow, current", itself from "ῥέω" (rheo), "to flow, to stream".

Epidemiology

Symptomatic hemorrhoids affect at least 50% of the American population at some time during their lives, with around 5% of the population suffering at any given time, and both sexes experiencing the same incidence of the condition. They are more common in Caucasians.

Prognosis

Hemorrhoids are usually benign.

Treatments

Conservative treatment typically consists of increasing dietary fiber, oral fluids to maintain hydration, non-steroidal anti-inflammatory drugs (NSAID)s, sitz baths, and rest. Increased fiber intake has been shown to improve outcomes, and may be achieved by dietary alterations or the consumption of fiber supplements.

While many topical agents and suppositories are available for the treatment of hemorrhoids, there is little evidence to support their use. Preparation H may improve local symptoms, but does not improve the underlying disorder, and long-term use is discouraged due to local irritation of the skin.
 Procedures

Rubber band ligation is a procedure in which elastic bands are applied onto an internal hemorrhoid at least 1 cm above the dentate line to cut off its blood supply. Within 5–7 days, the withered hemorrhoid falls off. If the band is placed too close to the dentate line, intense pain results immediately afterwards. Cure rate has been found to be about 87%.
Sclerotherapy involves the injection of a sclerosing agent, such as phenol, into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate four years after treatment is 70%.
A number of cautery methods have been shown to be effective for hemorrhoids. This can be done using electrocautery, infrared radiation, laser, or cryosurgery.

A number of surgical techniques may be used if conservative medical management fails. All are associated with some degree of complications including urinary retention, due to the close proximity to the rectum of the nerves that supply the bladder, bleeding, infection, and anal strictures.

Hemorrhoidectomy is a surgical excision of the hemorrhoid used primary only in severe cases. It is associated with significant post operative pain and usually requires 2–4 weeks for recovery.
Doppler guided transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate. However, there are less complications compared to a hemorrhoidectomy.
Stapled hemorrhoidectomy is a procedure that involves the resectioning of soft tissue proximal to the dentate line, disrupting the blood flow to the hemorrhoids. It is generally less painful than complete removal of hemorrhoids, and is associated with faster healing compared to a hemorrhoidectomy.

Differential

Many anorectal problems, including fissures, fistulae, abscesses,colorectal cancer, rectal varices and itching have similar symptoms and may be incorrectly referred to as hemorrhoids

Diagnosis

A visual examination of the anus and surrounding area may be able to diagnose external or prolapsed hemorrhoids. A rectal exam may be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses. This examination may not be possible without appropriate sedation due to pain, although most internal hemorrhoids are not present with pain.

Visual confirmation of internal hemorrhoids is via anoscopy or proctoscopy. This device is basically a hollow tube with a light attached at one end that allows one to see the internal hemorrhoids, as well as possible polyps in the rectum.

Prevention

The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass. Spending less time attempting to defecate and avoiding reading while on the toilet have been recommended

Pathophysiology

Hemorrhoid cushions are a part of normal human anatomy and only become a pathological disease when they experience abnormal changes. There are three cushions present in the normal anal canal.

They are important for continence, contributing to at rest 15–20% of anal closure pressure and act to protect the anal sphincter muscles during the passage of stool.

Causes

A number of factors may lead to the formations of hemorrhoids including irregular bowel habits (constipation or diarrhea), exercise, nutrition (low-fiber diet), increased intra-abdominal pressure (prolonged straining), pregnancy, genetics, absence of valves within the hemorrhoidal veins, and aging.

Other factors that can increase the rectal vein pressure resulting in hemorrhoids include obesity and sitting for long periods of time.

During pregnancy, pressure from the fetus on the abdomen and hormonal changes cause the hemorrhoidal vessels to enlarge. Delivery also leads to increased intra-abdominal pressures. Surgical treatment is rarely needed, as symptoms usually resolve post delivery

Signs and symptoms

Hemorrhoids usually are present with itching, rectal pain, or rectal bleeding.[2] In most cases, symptoms will resolve within a few days. External hemorrhoids are painful, while internal hemorrhoids usually are not unless they become thrombosed or necrotic.[2][3]

The most common symptom of internal hemorrhoids is bright red blood covering the stool, a condition known as hematochezia, on toilet paper, or in the toilet bowl.[2] They may protrude through the anus. Symptoms of external hemorrhoids include painful swelling or lump around the anus.

Internal

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. Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids. Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside the anus. If the anal muscle goes into and traps a prolapsed hemorrhoid outside the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid.
Internal hemorrhoids can be further graded by the degree of prolapse.
  • Grade I: No prolapse .
  • Grade II: Prolapse upon defecation but spontaneously reduce.
  • Grade III: Prolapse upon defecation and must be manually reduced.
  • Grade IV: Prolapsed and cannot be manually reduced.

External

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 internal pudendal artery. They are sometimes painful, and often accompanied by swelling and irritation. Itching, although often thought to be a symptom of external hemorrhoids, is more commonly due to skin irritation. External hemorrhoids are prone to thrombosis: if the vein ruptures and/or a blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid

Classification

There are two types of hemorrhoids, external and internal, which are differentiated via their position with respect to the