Hemorrhoids are enlarged veins located in the lower part of the rectum and the anus. They become swollen because of the 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. External hemorrhoids are located underneath the skin that surrounds the anus.
Hemorrhoids are associated with constipation and straining at bowel movements. Pregnancy is also associated with hemorrhoids. These conditions lead to increased pressure within the hemorrhoidal veins causing them to swell. Other conditions, such as chronic liver disease, may cause increased venous pressure and may be associated with hemorrhoid formation. Hemorrhoids are very common and are estimated to occur in up to one-half of the population by age fifty.
The most common symptom and sign from hemorrhoids is painless bleeding. There may be bright red blood on the outside of the stools, on the toilet paper, or dripping into the toilet. Bleeding with a bowel movement is never normal and should prompt a visit to a doctor. While hemorrhoids are the most common cause of bleeding with a bowel movement, there are other reasons to have bleeding including inflammatory bowel disease, infection, and tumors.
Prolapse of an internal hemorrhoid occurs when the internal hemorrhoids swell and extend from the location in the rectum through the anus. A prolapsed internal hemorrhoid can be gently pushed back through the anus, this may resolve the problem of prolapse but does not fix the hemorrhoid itself; may become entrapped, which requires medical attention. Hemorrhoids may also cause pruritus ani or itching around the anus, and a constant feeling of needing to have a bowel movement.
Thrombosed external hemorrhoids are a painful condition. These occurs when a blood clot develops in the hemorrhoid causing swelling and inflammation. When a blood clot occurs in hemorrhoid, the hemorrhoid will become even more swollen. This swelling leads to increased pain. The pain may be worse with bowel movements and may increase with sitting.
Bleeding from the rectum or anus is never normal and although hemorrhoids are the most common reason to have blood in the stool, it should be discussed with your primary health care practitioner. Other causes of rectal bleeding exist and can be serious. Inflammatory bowel disease and cancers of the colon can present with rectal bleeding. Medical care should be sought urgently if a person is taking anticoagulation medication such as warfarin, clopidogrel, or prasugrel.
Patients who have associated symptoms such as lightheadedness and weakness may have significant blood loss and may require more urgent care. Hemorrhoids do not cause abdominal pain; should this be present with bleeding, medical care should be accessed immediately. Prolapsed hemorrhoids that can not be pushed back through the anus require medical care. Thrombosed external hemorrhoids may cause significant pain and medical care may need to be sought.
Diagnosis of hemorrhoids is usually made by history and physical examination by the health care practitioner. Depending upon the situation, past medical history, medications and stability of the patient, treatment may follow with no further testing. If there is concern that significant bleeding has occurred, a complete blood count to measure hemoglobin and hematocrit levels is obtained. If the patient is on warfarin, a prothrombin time may be done to measure the blood clotting levels.
Inspection of the anus and a digital rectal examination are often performed. Sometimes anoscopy may be required where a small, lighted scope is introduced into the anus to examine the inner lining of the anus and rectum. The procedure is often performed in the office without sedation. If there is the potential that the bleeding source originated above the rectum from other parts of the colon, sigmoidoscopy or colonoscopy by a gastroenterologist may be recommended.
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