Hemorrhoids usually occur in right anterior position because of disruption of anchoring of anal cushions and are associated with irregular bowel movement and straining. During defection, straining swells the cushions, which results in their displacement, which when repeated results in stretching and eventual prolapse of cushions, called hemorrhoids.

Constipation and other conditions which result in irregular anal pressure and defiance predispose to hemorrhoid formations. Acquired situations like portal hypertension can cause swelling of venous plexuses that can contribute to displacement in anal cushion. Pregnancy also cause or aggravate the symptoms, direct pressure can play a role, however other factors like hormonal imbalance can contribute.

Consistent diarrhea and inflammatory bowel disease (IBD) can also cause hemorrhoid. Any sufferer with combination of IBD and hemorrhoid must take caution

Classification of Hemorrhoid

Hemorrhoids may be internal or external. Internal hemorrhoids are located proximal to dentate line which is made of insensate columnar glandular epithelium. It can prolapse, bleed or both. Sufferers are usually present with unexpected painless bleeding, often after bowel movement and should undergo orcolonoscopy or anoscopic examination to rule out diverticular or malignancy disease.

External Hemorrhoids are located distal to dentate line which is made up of sensate squamous epithelium, therefore sufferers usually report swelling, pain, itching or all.

Hemorrhoids can be graded as;

  • Primary or Grade I, which is usually with dietary changes, like increased fiber. If condition persist, rubber banding ligation or sclerotic therapy may be offered
  • Secondary or Grade II  that prolapse past anal verge however reduce naturally, usually treated with rubber banding or sclerotic therapy
  • Tertiary or Grade III that prolapse past anal verge and necessarily reduced through manual methods. Depending on size and symptoms, sufferers may be treated with rubber banding ligation, clerotic therapy, or surgery
  • Quaternary or Grade IV that prolapse past anal verge and aren’t reducible; surgical treatment like hemorrhoidectomy is preferred


To manage hemorrhoids surgically or medically, depends on severity of its symptoms

For primary and secondary, medical treatment is first line management that include bulk forming agents or dietary changes. Dietary changes is the basic treatment where sufferer has to ingest adequate water and fiber and to avoid straining. However these methods are only applicable for lesser prolapse.

For primary, secondary as well as some prolapsed secondary, few tertiary hemorrhoids and situations in which medical treatments are not adequate, office procedure are indicated as;

  • Infrared photocoagulation
  • Rubber band ligation
  • Sclerotherapy
  • Electrocoagulation
  • Cryotherapy

Surgery is only offered for cases where conservative management is not effective, such as large external hemorrhoids, hemorrhoid refractory to office procedures, prolapsed internal hemorrhoid and hemorrhoids with noticeable bleeding are treated with Hemorrhoid No More

  • Stapled hemorrhoidopexy
  • Open vs closed hemorrhoidectomy


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