Hemorrhoids: Types

1. Internal hemorrhoids
   • Originate above the dentate line (from the superior rectal venous plexus).
   • Covered by columnar epithelium → not painful (no somatic innervation).
   • Symptoms: painless bright red bleeding, prolapse, mucus discharge, and pruritus.
2. External hemorrhoids
   • Originate below the dentate line (from the inferior rectal venous plexus).
   • Covered by anoderm/skin → richly innervated → painful.
   • Symptoms: acute pain, swelling, and may thra ombose (bluish perianal lump).

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Differentiating Internal vs. External

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Grading of Internal Hemorrhoids (by degree of prolapse)

(Most widely used = Goligher’s classification)

• Grade I:
  • Hemorrhoids protrude into lumen but do not prolapse outside the anal canal.
  • Present with painless rectal bleeding only.
• Grade II:
  • Hemorrhoids prolapse outside anal canal during defecation but reduce spontaneously.
• Grade III:
  • Hemorrhoids prolapse during defecation or exertion and require manual reduction.
• Grade IV:
  • Hemorrhoids irreducibly prolapsed, permanently outside the anal canal.
  • May become thrombosed or strangulated.

📌 Mnemonic:

• I = In (never prolapse).
• II = Out, In (comes out but goes back in by itself).
• III = Out, Need Hand In (manual reduction needed).
• IV = Always Out (irreducible).

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Thrombosed External Hemorrhoid

• Definition: Acute clot (thrombus) formation within an external hemorrhoidal vein (below dentate line).
• Pathophysiology: Sudden venous rupture → blood clot trapped under skin → intense perianal pain.
• Clinical features:
  • Severe acute pain (esp. during sitting, coughing, defecation).
  • Tender bluish perianal nodule (subcutaneous).
  • Swelling, difficulty sitting.
  • Pain peaks in first 48–72 hrs, then gradually improves.
• Management:
  • If <72 hrs: Excision under local anesthesia (thrombectomy) → immediate pain relief.
  • If >72 hrs: Conservative (analgesics, sitz baths, stool softeners, Daflon).

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Acute vs. Chronic Hemorrhoids

• Acute Hemorrhoids
  • Sudden onset, often due to thrombosis.
  • Severe pain (esp. external).
  • Perianal swelling, tender bluish nodule.
  • Acute bleeding is possible.
  • Usually self-limited but very symptomatic.
• Chronic Hemorrhoids
  • Long-standing, recurrent symptoms.
  • Painless rectal bleeding during defecation.
  • Prolapse (grades II–IV).
  • Pruritus ani, mucus discharge, soiling.
  • Pain only if thrombosed or strangulated.

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Cut-off Between Acute vs. Chronic Hemorrhoids

Acute Hemorrhoids

• Definition: New, sudden event, usually due to thrombosis or strangulation of a hemorrhoidal vein.
• Time course: Symptoms develop within hours to days.
• Main hallmark: Severe pain + perianal swelling (external or prolapsed thrombosed internal).
• Course: Self-limited, resolves in days to ~2 weeks, even without surgery (though excision may speed recovery).

👉 Cut-off: Acute = Thrombosed or strangulated hemorrhoid with symptoms < 2 weeks.

Chronic Hemorrhoids

• Definition: Long-standing vascular cushion enlargement with recurrent symptoms.
• Time course: Symptoms persist or recur for weeks to months.
• Main hallmark:
  • Painless rectal bleeding during/after defecation.
  • Prolapse (graded I–IV).
  • Mucus discharge, pruritus, soiling.
  • Pain only if thrombosed (then → acute flare on chronic).

👉 Cut-off: Chronic = Recurrent or persistent symptoms > 2 weeks with structural changes (bleeding, prolapse, pruritus, mucus).

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✅ Hemorrhoids Management

1. Conservative / Medical Management

Indicated for:

• Grade I–II internal hemorrhoids.
• External hemorrhoids (non-thrombosed).
• Chronic hemorrhoids without severe prolapse.

Measures:

• Lifestyle: High-fiber diet (20–35 g/day), hydration, avoid straining, regular exercise.
• Sitz baths: 10–15 min × 2–3/day.
• Stool softeners/laxatives: Docusate, PEG.
• Medications:
  • Daflon (MPFF) – venotonic, reduces bleeding/inflammation.
  • Topical hydrocortisone, lidocaine, and witch hazel.
  • NSAIDs / acetaminophen for pain.

2. Office-Based / Minimally Invasive Procedures

Indicated for:

• Grade II–III internal hemorrhoids refractory to conservative therapy.

Options:

• Rubber band ligation (most effective for Grade II–III).
• Sclerotherapy (phenol injection).
• Infrared coagulation / bipolar diathermy.

3. Surgical Management (Hemorrhoidectomy / Stapled Hemorrhoidopexy)

Indicated for:

• Grade IV internal hemorrhoids (irreducible prolapse).
• Large Grade III hemorrhoids not responding to rubber band ligation.
• Thrombosed external hemorrhoid (within 72 hrs of onset → excision under local anesthesia).
• Recurrent bleeding with anemia.
• Mixed hemorrhoids (internal + external).

Surgical Options:

• Excisional hemorrhoidectomy (Milligan-Morgan or Ferguson) – gold standard for advanced hemorrhoids.
• Stapled hemorrhoidopexy – for circumferential prolapse.
• Thrombectomy – for acute painful thrombosed external hemorrhoids (<72 hrs).

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High-Yield

• Grade I–II → Medical/office procedures.
• Grade III → Start with rubber band ligation; surgery if refractory.
• Grade IV → Surgery definitive.
• Thrombosed external hemorrhoid → excision if <72 hrs (best pain relief).

In summary:

• Medical + lifestyle → Grades I–II.
• Office procedures → Grade II–III.
• Surgery → Grade IV, large/refractory Grade III, thrombosed external hemorrhoids, recurrent severe bleeding.