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balloon expulsion, although imaging of the anal sphincter and pelvic floor are usually
required to better define structural pathology.
7
ARM as the most commonly performed test of anal motor function and assesses the
pressure in the anal canal at rest and during voluntary effort, as well as simulated
defecation.
Newer diagnostic tools, such as the EndoFLIP for the assessment of anal distensibility,
have not yet entered routine clinical practice.
Testing of anorectal neurophysiology to investigate peripheral neural injury, especially
after deliver using EMG and PNTML, is highly operator dependent and mostly performed
in specialist centers.
Rectal sensory and motor function can be tested by rectal barostat studies or by
syringe-driven balloon distension.
The ability to evacuate is tested by BET, where patients are asked to expel a water-filled
balloon attached to a Foley catheter sitting on a commode in privacy.
Conventional defecography and MRD allow identification of structural rectal abnormalities such as rectocele or enterocele with intu ssusception. Furthermore, they can
assess pelvic floor descent and rectal emptying of applied contrasts. MRD has the advantage of not exposing the patient to radiation and giving detailed, dynamic information on
the surrounding pelvic-floor anatomy.
All tests of anorectal structure and function are subject to several limitations. Except for
the BET, barium proctography, and in some cases MRD, investigations are performed in
the unphysiological left-lateral position instead of the physiological upright sitting position. This has an impact on measurements and patient behavior. Furthermore, embarrassment due to the awkward nature of the investigations may inhibit normal push effort,
possibly leading to overdiagnosis of DD and impaired evacuation. Additionally, none of
the current tests of evacuation are performed in response to the spontaneous desire to
defecate. Furthermore, variations in equipment, paucity of normative data, lack of sta ndardized terminology and protocol s, as well as limited availability of standardized metrics
for the analysis of anorectal tests need to be taken into account when interpreting anorectal tests.
23
However, HR-ARM, 3D-ARM, EndoFLIP, and short protocol barostat devices are promising tools in the armamentarium for the diagnosis of AD and will change clinical practice
to enable more comprehensive and rapid assessment of FI and ED.
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46 ANORECTAL DISORDERS
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Chapter 4 • Diagnostic Tools in Anorectal Disorders 47
24. Carlson DA, Kahrilas PJ, Ritter K, Lin Z, Pandolfino JE. Mechanisms of repetitive retrograde contrac-
tions in response to sustained esophageal distension: a study evaluating patients with postfundoplication dysphagia. Am J Physiol Gastrointest Liver Physiol. 2018;314(3):G334–G340.
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32. Dvorkin LS, Chan CL, Knowles CH, Williams NS, Lunniss PJ, Scott SM. Anal sphincter morphology in
patients with full-thickness rectal prolapse. Dis Colon Rectum. 2004;47(2):198–203.
33. Abdool Z, Sultan AH, Thakar R. Ultrasound imaging of the anal sphincter complex: a review. Br
J Radiol. 2012;85(1015):865–875.
34. Mahony R, Behan M, Daly L, Kirwan C, O’Herlihy C, O’Connell P. Internal anal sphincter defect
influences continence outcome following obstetric anal sphincter injury. Am J Obstet Gynecol.
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35. Titi M, Jenkins J, Urie A, Molloy R. Correlation between anal manometry and endosonography in
females with faecal incontinence. Colorectal Dis. 2008;10(2):131–137.
36. Pinsk I, Brown J, Phang P. Assessment of sonographic quality of anal sphincter muscles in patients with
faecal incontinence. Colorectal Dis. 2009;11(9):933–940.
37. Townsend D, Carrington E, Grossi U, et al. Pathophysiology of fecal incontinence differs between men
and women: a case-matched study in 200 patients. Neurogastroenterol Motil. 2016;.
38. Albuquerque A, Pereira E. Current applications of transperineal ultrasound in gastroenterology.
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39. Hainsworth AJ, Solanki D, Hamad A, Morris SJ, Schizas AM, Williams AB. Integrated total pelvic floor
ultrasound in pelvic floor defaecatory dysfunction. Colorectal Dis. 2017;19(1):O54–O65.
40. Sauter M, Heinrich H, Fox M, et al. Toward more accurate measurements of anorectal motor and sen-
sory function in routine clinical practice: validation of high-resolution anorectal manometry and
Rapid Barostat Bag measurements of rectal function. Neurogastroenterol Motil. 2014;26(5):685–695.
41. Sun WM, Read NW, Miner PB. Relation between rectal sensation and anal function in normal subjects
and patients with faecal incontinence. Gut. 1990;31(9):1056–1061.
42. Bharucha AE. Update of tests of colon and rectal structure and function. J Clin Gastroenterol. 2006;
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43. Chiarioni G, Kim SM, Vantini I, Whitehead WE. Validation of the balloon evacuation test: reproduc-
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48 ANORECTAL DISORDERS
44. Rao SS, Ozturk R, Laine L. Clinical utility of diagnostic tests for constipation in adults: a systematic
review. Am J Gastroenterol. 2005;100(7):1605–1615.
45. Palit S, Thin N, Knowles CH, Lunniss PJ, Bharucha AE, Scott SM. Diagnostic disagreement between
tests of evacuatory function: a prospective study of 100 constipated patients. Neurogastroenterol Motil
Off J Eur Gastrointest Motil Soc. 2016;28(10):1589–1598.
46. Dedeli O, Turan I, Ozturk R, Bor S. Normative values of the balloon expulsion test in healthy adults.
Turk J Gastroenterol Off J Turk Soc Gastroenterol. 2007;18(3):177– 181.
47. Van Koughnett JA, da Silva G. Anorectal physiology and testing. Gastroenterol Clin North Am. 2013;
42(4):713–728.
48. Lunniss PJ, Gladman MA, Benninga MA, Rao SS. Pathophysiology of evacuation disorders. Neurogas-
troenterol Motil Off J Eur Gastrointest Motil Soc. 2009;21(suppl 2):31–40.
49. Mortele KJ, Fairhurst J. Dynamic MR defecography of the posterior compartment: indications, tech-
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https://doi.org/10.1111/codi.13657.
Chapter 4 • Diagnostic Tools in Anorectal Disorders 49
5
Hemorrhoidal Disease
Varut Lohsiriwat
DE P A R T M EN T O F S U R G E R Y , F A CU L T Y OF M E D IC I N E S I R I R A J H O S P I T A L , M A H I D O L U N I V E R S I T Y ,
BA N G K O K , T H A I L A N D
5.1 Introduction
Hemorrhoids comprise one of the most common anorectal diso rders seen in gastrointestinal clinics. Patients with hemorrho ids usual ly present with painless bleeding
and/or a prolapsed lesion per anus during bowel movement. Hemorrhoids are associated with the engorgement of blood ves sels within the hemorrhoid venous plexus
and the disintegration of supporting connective tissue within the anal cushions.
1
This chapter compre hensively reviews the prevalence, risk factors, pathophysiology,
classification, clinical evaluation, and nonsurgical management of hemorrhoids
including medication, lifestyle modification, and some office-based procedures.
The treatment options for hemorrhoids in special groups of patients such as individuals taking anticoagulants or antiplatelet drugs, pregnant women, and those w ith
impaired immunity are also d iscussed.
5.2 Prevalence and Risk Fact ors
Although hemorrhoids comprise a common anorectal disease, data on th eir prevalence are limited because many patients do not seek medical attention. In 1990 a large
epidemiologic study in the United States showed that 4.4% of general population suffered from hemorr hoids, especially wh ite individuals with high socioeconomic status,
with a peak prevalence at the age of 45–65 years.
2
In the United Kingdom, its incidence
was reportedly about 8–34 per thousand per year or equi valent to a prevalence of
28–133 per thousand.
3
A study from Austria in 2009 demonstrated a prevalence of
39% in i ndividuals attending a nationwide colorectal screening program, but only
45% were symptomatic and the majority had low-grade hemorrhoids.
4
High body
mass index was found to be one o f the risk factors for hemorrhoid development in
the Western population.
Constipation and prolonged straining is also believed to be a leading cause of hemorrhoid development or an aggravating factor for developing acute symptoms of hemorrhoids, since increased intraabdominal pressure interferes with pelvic venous drainage
Anorectal Disorders.
https://doi.org/10.1016/B978-0-12-815346-8.00005-9
© 2019 Elsevier Inc. All rights reserved.
51
causing the congestion of hemorrhoid venous plexus. In women, pregnancy was also an
important factor for hemorrhoid development. Degenerative changes in supporting connective tissue within the anal cushions, together with a direct injury to the anal cushions
from hard stools, can lead to hemorrhoid development. Diarrhea or frequent defecation
could be linked to acute hemorrhoid attack. Some personal habits were reportedly associated with hemorrhoids such as a sed entary lifestyle and the consumption of a low-fiber
diet, spicy food, or alcoholic bev erages.
1
5.3 Pathophysiology
It is not yet fully understood how hemorrho ids develop. Several pathogeneses of
hemorrhoids have been proposed incl uding sliding anal c ushions , rectal redundancy,
vascular abnormality, and tissue inflammation.
1
The diffe rent pathophysiologi es may
result in different approaches to hemorrhoids.
5
The theory of sliding anal cushions is
arguabl y the most widely accepted pathophysiology for hemorrhoids suggesting that
hemorrhoids develop when the supporting connective tissues of the anal cushions
disintegrate or deteriorate. The downward displaceme nt of anal cushions caused
the engorgement of hemorrhoid plexus thu s leading to symptomatic hemorrhoids.
Destruc tive changes in elastin and collagen t issue of anal cushions may be a result
of aging, mechanical injury from hard stools, and a high level of matrix metalloproteinase s—the main extracellular matrix enzyme involv ing collagen degradation and
tissue modeling.
6
Some investigators analyzed the quantity and quali ty of collagen
formati on and found that hemorrh oids had less type I collagen (dense and mature)
but more type III collagen (thinner and immature) than that of normal anal tissue
suggesting that abnormalities in c ollagen composition may contribute to hemorrhoid
formation.
7
Some surgeons advocated that a prolapsed hemorrhoid was related to an internal
rectal prolapse or rectal redundancy, and recommended that circumferential prolapsed
hemorrhoids may be treated with stapled hemorrhoidopexy—an operation involving
the circumferential removal of abnormally redundant mucosa just above the apex of
hemorrhoids, followed by the repositioning of the remaining hemorrhoid tissue back to
its normal anatomical position.
In recent years research that has demonstrated abnormalities in vascular structure, neovascularization, and dysre gulation of blood flow in hemorrhoids has gained
more attention and physi cians have thus tried to develop novel approaches to treat
hemorrhoids. A study of the morphology and hemodynamics of the ar terial supply to
the anorectal region demonstrated that the diameter and blood flow of superior hemorrhoidal arteries were proportionally related to the severity of the hemorrhoids suggesting a high anore ctal perfusion in patients with hemorrhoids.
8
It was also evident
that there was an imbalance betwe en vasodilation and vasoconstriction in hemorrhoids.
9
Moreover, hemorrhoid tissue contained newly formed microvessels and
some inflammatory cells.
10
52 ANORECTAL DISORDERS
5.4 Classification
In general, hemorrhoids can be classified into three groups depending on their location:
external, internal, and combined (mixed) type. External hemorrhoids are located distal to
the dentate line and covered by skin—sometimes known as perianal skin tag. Internal
hemorrhoids are covered by anal mucosa and located above the dentate line. Mixed hemorrhoids are a combination of internal lesions and external lesions (
Fig. 5.1). Since internal
hemorrhoids are originally from anal cushions, the common positions of internal hemorrhoids are therefore where the major anal cushions are located at the left lateral aspect
(3 o’clock), right posterior aspect (7 o’clock), and left anterior aspect (11 o’clock) of the
anal canal.
Internal hemorrhoids are further graded based on their appearance and degree of
prolapse as (
Fig. 5.2):
1. First-degree hemorrhoids (grade I): The anal cushions bleed but do not prolapse;
2. Second-degree hemorrhoids (grade II): The anal cushions prolapse through the anus
on straining and reduce spontaneously;
3. Third-degree hemorrhoids (grade III): The anal cushions prolapse through the anus on
straining and require manual reduction; and
4. Fourth-degree hemorrhoids (grade IV ): The prolapse stays out at all times and is
irreducible.
First-degree (grade I) and second-degree (grade II) hemorrhoids are regarded as “lowgrade” internal hemorrhoids, whereas third-degree (grade III) and fourth-degree (grade
IV) hemorrhoids are known as “high-grade” hemorrhoids. Acutely thrombosed hemorrhoids, incarcerated internal hemorrhoids, and strangulated hemorrhoids are considered
as “complicated” hemorrhoids and usually required surgical interventions.
11
FIG. 5.1 Internal hemorrhoids, external hemorrhoids, and mixed (combined) hemorrhoids.
Chapter 5 • Hemorrhoidal Disease 53
5.5 Clinical Evaluation
The leading symptoms of hemorrhoids are painless bleeding and/or prolapsed lesions per
anus during straining or defecating. Patients usually notice small amounts of bright red
blood on the surface of stool, on toilet tissue, or in the toilet bowl. However, if blood is
mixed with the stool this indicates that the bleeding is likely from the rectum or
colon—not from hemorrhoids. Meanwhile, mucous bloody stool suggests rectal malignancy or inflammatory bowel diseases. Although internal hemorrhoids appears to be a
group of venous vessels, bright red blood in bleeding hemorrhoids is a result of direct arteriovenous communication within the hemorrhoid plexus. Anemia is uncommon in
patients with bleeding hemorrhoids except those with massive bleeding or those with a
prolonged period of anal bleeding. Should low hematocrit level be found in patients with
hemorrhoids, other causes of anemia should be evaluated such as thalassemia and gastrointestinal malignancy. Patients at risk for colorectal cancer, such as individuals aged 50
and older, or those with a family history of colorectal cancer, should undergo colonoscopy.
Pain is also uncommon in symptomatic hemorrhoids except in “complicated” hemorrhoids. Should patients experience pai n during defecation, other etiologies such as anal
fissure and anal cancer need to be considered. Some patients with large or high-grade
hemorrhoids may experience discomfort, itching, swelling, or irritation in the anal region.
FIG. 5.2 Grades of internal hemorrhoids.
54 ANORECTAL DISORDERS
The diagnosis of hemorrhoids relies on a thorough history and adequate physical
examination including digital rectal examination and anoscopy. In general, uncomplicated or low-grade internal hemorrhoids are not painful or palpable. If digital rectal examination identifies a palpable lesion, other disease such as anorectal neoplasms should
be of concern. Following digital rectal examination, anoscopy should be performed to
evaluate the number, location, and extent of internal hemorrhoids, and to determine
whether it is associated with bleeding or thrombosis.
5.6 Management of External Hemorrhoids and Their
Complications
External hemorrhoids may not require any treatment unless they are large, interfere with
an individual’s activities of daily living, or appear simultaneously with high-grade internal
hemorrhoids.
11
In such cases a physician may consider surgical removal of those lesions.
The most common complication of external hemorrhoids is acute thrombosis. Patients
with acutely thrombosed external hemorrhoids often seek medical attention because of
acute and severe anal pain together with a hard lump at the anal margin. Some patients
may give a recent history of prolonged straining, constipation, or coughing that caused
venous stagnation and clot formation within the hemorrhoid plexus. Thrombosed external hemorrhoids can be solely diagnosed based on clinical grounds in which a dark-blue
or purple, hard, and painful lump is found at the anal verge. Notably the bluish-purplish
discoloration under the skin is a result of clot formation, which is different from a malignant melanoma—in which its dark color comes from melanocytes in the epidermis. Other
differential diagnoses for thrombosed external hemorrhoids include perianal abscess and
intersphincteric abscess—in which a painful lump in the anal canal or the perianal region
is often accompanied by fever and/or pus drainage.
Patients with acutely thrombosed external hemorrhoids usually exp erience acute pain
peaking at 24–48 h and beginning to reduce by the third or fourth day as the clot is spontaneously resolved. Pain intensity is a key determinant for treatment planning. If patients
have minimal pain or a decline in pain intensity, conservative treatment should be considered including oral analgesia, stool softener, and warm sitz baths. After successful conservative management, whether the lump will completely disappear or remain as a
redundant perianal skin tag is unpredictable. However, if patients have severe or persisting
pain, clot evacuation or surgical excision of the thrombosed hemorrhoid will be a treatment of choice.
12
5.7 Management of Internal Hemorrhoids
Management of internal hemorrhoids mainly depends on the grade and severity, patient’s
preference, and the skill or expertise of physician. In general, low-grade internal hemorrhoids are easily treated conservatively with medication and/or office-based procedures,
Chapter 5 • Hemorrhoidal Disease 55
e.g., rubber-band ligation and sclerotherapy. An operation is reserved for hig h-grade internal hemorrhoids, combined internal and external hemorrho ids, strangulated or thrombosed hemorrhoids, and those who fail nonoperative management.
5,11
This chapter
will focus exclusively on nonsurgical management of internal hemorrhoids.
5.7.1 Dietary and Lifestyle Modification
A metaanalysis of seven randomized controlled trials examining the effect of fiber on
symptomatic hemorrhoids showed that fiber supplement or increased dietary fiber
reduced the risk of bleeding by half but had no significant effect on prolapse, pain, and
itching.
13
One study sugge sted a decrease in recurrence. Although fiber supplement or
increased dietary fiber appears to have limited beneficial effects on hemorrhoids, it is relatively cheap, easy to apply, and has mild adverse events, for example, bloating and flatulence. As a result, many physicians advise patients with internal hemorrhoids to increase
fiber uptake as an initial treatment for symptomatic hemorrhoids or a preventive measure
for recurrence.
1,14
Knowing that some lifestyle and eating habits may aggravate the symptoms of hemorrhoids, it is worth advising patients to modify their personal habits as an integrated part of
the conservative treatment of hemorrhoids. The advice usually includes increasing the
intake of dietary fiber and oral fluids, reducing the consumption of spicy food and alcoholic beverages, having regular exercise, refraining from straining and reading on the
toilet, and avoiding medication causing constipation or diarrhea.
1
5.7.2 Topical Medication
The primary aim of applying topical agents on hemorrhoids is to control the symptoms
rather than to cure the disease. Thus other treatments are usually required. Topical agents
may contain various ingredients such as lubricants, local anesthetic agents, corticosteroids, antibiotics, and antiinflammatory drugs. Some agents may contain nitrate or calcium channel blocker, which helps to relax the internal anal sphincter and reduce the
congestion of hemorrhoids or pain intensity after hemorrhoidectomy.
15,16
They are available in various preparations such as suppositories, cream, and ointment. Most of them
can be bought without a prescription. However, there is a very limited strong evidence
supporting the true efficacy of these drugs for the treatment of symptomatic
hemorrhoids.
1
Since hemorrhoids are associated with the hyperperfusion of the anorectal region and
venodilatation, any pharmacological interventions enhancing vascular contraction, especially topical agents that act locally, would be of great interest. Currently, there are a few
topical products containing vasoactive agents such as phenylephrine.
1
Recently, Lohsiriwat and his colleagues found that the vasculature of hemorrhoids contained endothelin
receptors and endothelin-1 mediated vasoconstriction in the human splanchnic blood
flow. They suggested that endothelin-1 and its receptors on hemorrhoids could be a
potential site for medical intervention for low-grade hemorrhoids.
9
56 ANORECTAL DISORDERS
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