Hemorrhoids

Hemoroider er en svært vanlig tilstand som oppstår når blodfylte puter i endetarmen blir Hemorrhoids are a very common condition that occurs when blood-filled cushions in the rectum become enlarged or displaced. This can cause symptoms such as pain, itching, bleeding, or a sensation of something bulging out of the anal opening. In some individuals, hemorrhoids cause no discomfort, while in others they may lead to significant daily problems. The condition is closely linked to anatomy and pressure dynamics in the pelvis and rectum, and understanding these aspects is important for both diagnosis and treatment.

The condition is also referred to as hemorrhoids (English spelling), anal varices, and anal cushions. In English, both “hemorrhoids” and “piles” are commonly used.

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Causes and Pathophysiology

The anal region contains three main cushions that normally contribute to the fine-tuning of the anal closure mechanism. These cushions are richly vascularized and typically located at the 11, 3, and 7 o’clock positions of the anal opening. They are supported by connective tissue and smooth muscle and receive blood from the superior rectal artery¹. When these structures weaken or become displaced, they may develop into hemorrhoids.

Two main theories explain the development:

1. The Sliding Theory

This theory explains that hemorrhoids arise when the connective tissue and musculature that hold the internal anal cushions in place weaken. With increased pressure, for example during straining at defecation, the cushions may slide downward and outward. This results in both mechanical protrusion and increased inflammatory activity, and may lead to venous dilation, small thromboses, and tissue changes².

2. Hemodynamic Theory

This theory suggests that increased arterial inflow and reduced venous outflow in the rectal cushions cause pooling and enlargement. Smooth muscle around the vessels attempts to regulate this, but with prolonged strain, outpouchings and varicosities may occur³.

Histological studies of hemorrhoidal tissue also show signs of neovascularization and increased activity of proteins affecting connective tissue and blood vessels, such as VEGF and MMP⁴.

Risk Factors

Several factors may contribute to the enlargement or displacement of the anal cushions:

• Chronic constipation and hard stools requiring excessive straining

• Diarrhea causing frequent stress to the anorectal region

• Pregnancy and childbirth, especially due to pressure and hormonal changes in connective tissue

• Frequent and prolonged toilet use, particularly in a sitting position

• Poor dietary habits, especially low fiber intake

• Heavy lifting and activities that increase intra-abdominal pressure

Symptoms and Clinical Presentation

Approximately 4 out of 10 individuals with hemorrhoids experience symptoms⁵. The type and severity of symptoms depend on the type and grade:

Internal hemorrhoids:

• Painless bleeding (bright red blood) during defecation

• Sensation of bulging or prolapse

• Mild moisture or mucus leakage

• Pain is less common, unless complications occur

External hemorrhoids:

• Painful swelling at the anal opening, especially if thrombosed

• Visible lump, often bluish or purple

• Tenderness and discomfort when sitting

• Itching or irritation

Diagnosis

A thorough medical history and clinical examination are essential to establish the correct diagnosis and exclude more serious conditions⁶.

During examination, clinicians assess:

• Skin changes, lumps, and discoloration around the anal opening

• Hard, tender, bluish nodules suggestive of thrombosed external hemorrhoids

• Presence of fecal soiling on the skin

• Pain or fissures

Digital rectal examination: Although internal hemorrhoids are rarely palpable, this step is crucial to exclude tumors, fistulas, or scar tissue.

Anoscopy: A short tube is inserted into the anal canal to visualize internal hemorrhoids, allowing assessment of size, location, and possible inflammation.

Colonoscopy: Used in cases of bleeding in patients over 50 years of age, or when other colonic pathology is suspected⁷.

Classification

Hemorrhoids are classified based on their relation to the pectinate line:

• Internal hemorrhoids: Arise above the pectinate line, usually painless.

• External hemorrhoids: Arise below the pectinate line, often painful.

Internal hemorrhoids are further graded:

• Grade I: Visible, but without prolapse

• Grade II: Prolapse during straining, but spontaneously reduce

• Grade III: Prolapse requiring manual reduction

• Grade IV: Permanent prolapse, irreducible

Treatment and Medical Management

Treatment of hemorrhoids depends on grade, symptoms, and whether complications such as thrombosis or persistent bleeding are present. Options include conservative measures, pharmacological therapy, non-surgical interventions, and surgery. Often, a combination yields the best results.

Conservative treatment:This is the first-line approach for mild to moderate symptoms. The goal is to reduce straining during defecation and provide symptom relief.

• Dietary modifications with increased fiber intake and adequate fluid consumption

• Avoid straining and prolonged toilet sitting

• Warm sitz baths several times daily

• Stool softeners if necessary

Pharmacological treatment:

• Local creams and suppositories with analgesic or anti-inflammatory effects

• Plant-based medications (so-called phlebotonics) that improve venous drainage and strengthen capillaries, especially for grade I and II hemorrhoids or acute thrombosis

• Corticosteroids and non-steroidal anti-inflammatory drugs (NSAIDs) for inflammation

• Laxatives to reduce straining and constipation⁹

Physiotherapy

The role of physiotherapy is to reduce strain on the pelvis and rectum, promote normal bowel movements, and address secondary muscular tension.

Non-Surgical Interventions

These procedures are usually performed on an outpatient basis and are effective in early stages or in patients who do not wish to undergo surgery.

Electrocoagulation:

Direct current is applied to the base of the hemorrhoid via an anoscope. The current (8–16 mA) cauterizes the tissue, which subsequently necroses and disappears. Used in grade I–III hemorrhoids.

Sclerotherapy:

Chemical agents such as polidocanol or zinc chloride are injected into the hemorrhoidal cushions. This leads to tissue contraction and reduced blood supply. Effective for grade I and II hemorrhoids, and requires no anesthesia¹².

Rubber band ligation:

A tight rubber band is placed around the base of the hemorrhoid, cutting off its blood supply. Within 3–7 days the tissue necroses and detaches spontaneously¹³.

Surgical Treatment

Surgery is considered in severe or recurrent cases, or when other measures fail to provide adequate relief.

Hemorrhoidectomy:

Surgical excision of hemorrhoidal tissue, performed either open or closed. It offers a low risk of recurrence but is associated with significant pain, delayed healing, and complications such as:

• Urinary retention (up to 34%)

• Bleeding (1–2%)

• Persistent pain lasting several weeks⁸

Stapled hemorrhoidopexy:

Hemorrhoidal tissue is excised and repositioned higher in the rectum using a circular stapling device. Because the procedure occurs above the pectinate line, postoperative pain is reduced. A rare complication in women is rectovaginal fistula if vaginal tissue is inadvertently stapled⁸.

Doppler-guided hemorrhoidal artery ligation:

An ultrasound probe identifies the arteries supplying the hemorrhoid, which are then ligated to reduce blood flow, causing the hemorrhoid to shrink⁸. gjør at hemoroiden skrumper inn⁸.

Differential Diagnoses

Several conditions may present with similar symptoms and must be carefully distinguished:

• Anal fissure: A mucosal tear causing sharp pain, especially during defecation, often with small amounts of blood. Typically associated with hard stool or local trauma.

• Perianal fistula or abscess: Presents with increasing pain, fever, and discharge. A small opening may be visible around the anus.

• Colorectal cancer: Any rectal bleeding must be evaluated for malignancy, particularly in patients over 50 years.

• Inflammatory bowel disease (IBD): Chronic intestinal inflammation may cause both rectal bleeding and engorged vessels.

Sources

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2. Lee JM, Kim NK. Important anatomy in the anorectal region for colorectal surgeons with emphasis on macroscopic and histological findings. Annals of Coloproctology. 2018;34(2):59.

3. Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World Journal of Gastroenterology. 2012;18(17):2009.

4. Lalisang TJ. Hemorrhoids: pathophysiology and surgical management. The New Ropanasuri Journal of Surgery. 2016;1(1).

5. Aigner F, Gruber H, Conrad F, Eder J, Wedel T, Zelger B, et al. Revised morphology and hemodynamics of the anorectal vascular plexus: relevance for hemorrhoidal disease. International Journal of Colorectal Disease. 2009;24:105–13.

6. Margetis N. Pathophysiology of internal hemorrhoids. Annals of Gastroenterology. 2019:264–.

7. Sun Z, Migaly J. Review of hemorrhoid disease: presentation and management. Clinics in Colon and Rectal Surgery. 2016;29(1):22–9.

8. Higuero T, Abramowitz L, Castinel A, Fathallah N, Hemery P, Duhoux CL, et al. Guidelines for hemorrhoid management. Journal of Visceral Surgery. 2016;153(3):213–8.

9. Chiu JH, Chen WS, Chen CH, Jiang JK, Tang GJ, Lui WY, et al. The effect of transcutaneous nerve stimulation on pain relief after hemorrhoidectomy: a prospective, randomized controlled study. Diseases of the Colon & Rectum. 1999;42(2):180–5.

10. Kenway M. Six treatments for hemorrhoid pain and bleeding – complete physiotherapy guide to home remedies. Available from: http://www.youtube.com/watch?v=qTcb55KOK9Y

11. He A, Chen M. Sclerotherapy in hemorrhoids. Indian Journal of Surgery. 2023;85(2):228–32.

12. Albuquerque A. Rubber band ligation of hemorrhoids: a guide to complications. World Journal of Gastrointestinal Surgery. 2016;8(9):614.