Hemorrhoids pathophysiology: Difference between revisions

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Revision as of 19:51, 22 August 2017

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Overview

Hemorrhoids develop due to a combination of genetic predisposition (weak rectal veins) and certain diet and defecation habits.

Pathophysiology

Hemorrhoids can be internal and external.

Internal hemorrhoids are located above the dentate line and they occur due to dilatation of the superior hemorrhoidal plexus.

The connective tissue over the superior hemorrhoidal plexus is innervated via visceral nerves and thus it is pain insensitive.

External hemorrhoids are located below the dentate line and occur due to dilatation of the inferior hemorrhoidal plexus.

The first step in the pathogenesis of either type of hemorrhoids is weakening of the surrounding connective tissue and vein wall. All the risk factors (old age, pregnancy, portal hypertension, etc) lead to aggravating this weakness or add more pressure from within the vein.

Increased tone of the internal anal sphincter causing the feces to press the hemorrhoid against the muscle and thus decreasing venous return and aggravating the symptoms.

The arteriovenous anastomosis may play a role in the development of hemorrhoids. This is supported by the fact that some hemorrhoids improve after ligating the connecting arteries.

The redundant bulging mucosa is easily injured causing bleeding. The blood is usually bright red reflecting high oxygen content due to the proximity of AV anastomosis.

Gross pathology

External hemorrhoids appear on inspection of the anal verge as skin tags or strangulated or free prolapsed veins.
Internal hemorrhoids appear as bluish bulgings of the veins in the mucosa.

By Dr. Joachim Guntau - www.Endoskopiebilder.de, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=18660152	By Dr. Joachim Guntau - www.Endoskopiebilder.de, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=18660115
By Tmalonetn - Own work, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=10358212	By Internet Archive Book Images - httpswww.flickr.comphotosinternetarchivebookimages14784684835Source book page httpsarchive.orgstreamdiseasesofrectum00gantdiseasesofrectum00gant-pagen490mode1up, No restrictions, ht

References

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-===Food===
-* [[Chronic constipation]] can cause hemorrhoidal irritation due to hard stools.<ref name="pmid17074235" />
-* An excess of [[lactic acid]] in the stool, a product of excessive consumption of dairy products such as cheese, can cause [[irritation]]. A reduction of consumption of these foods can bring relief.
-* [[Vitamin E]] deficiency is also a common cause.
-* Consuming probiotic foods such as yogurt with active culture or consuming fruit may help keep the gut functioning normally and prevent flare-ups.
-=== Use of unnatural "sitting" 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 unnatural "sitting" toilet.<ref>{{cite journal |author=Sikirov BA |title=Primary constipation: an underlying mechanism |journal=Med. Hypotheses |volume=28 |issue=2 |pages=71–3 |year=1989 |pmid=2927355 |doi=}}</ref><ref>{{cite journal |author=Sikirov D |title=Comparison of straining during defecation in three positions: results and implications for human health |journal=Dig. Dis. Sci. |volume=48 |issue=7 |pages=1201–5 |year=2003 |pmid=12870773 |doi=}}</ref>
-* In 1987, an Israeli physician, Dr. Berko Sikirov, published a study testing this hypothesis by having hemorrhoid sufferers convert to [[squat toilets]].<ref name="pmid3623887">{{cite journal |author=Sikirov BA |title=Management of hemorrhoids: a new approach |journal=Isr. J. Med. Sci. |volume=23 |issue=4 |pages=284–6 |year=1987 |pmid=3623887 |doi=}}</ref> 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.
-* No follow-up studies have ever been published.
-* The American Society of Colon & Rectal Surgeons has not published any recommendations regarding the therapeutic value of squatting.
 ==Gross pathology==