Hemorrhoids

Hemorrhoids are normal vascular cushions in the anal canal composed of dilated vascular tissue, smooth muscle, and connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue. They do not cause issues unless they are enlarged, inflamed, thrombosed, or prolapsed. Patients often present with rectal bleeding of bright red blood, or they may have pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, perianal pruritus, or a palpable mass. Risk factors include family history, low-fiber diet, and constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation. The two main types of hemorrhoids are external, usually with perianal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, and internal, which are usually painless. The main diagnostic tools are history, physical exam, and endoscopic procedures if indicated for further investigation. If symptoms are acute, excision can be performed for external hemorrhoids. Otherwise, conservative management is recommended. Surgical methods are reserved for more severe hemorrhoids or those unresponsive to primary treatment.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definition

Hemorrhoids are normal swollen vascular structures in the anorectal canal.

  • Vascular cushions that assist with stool passage: 
    • Originate from channel of arteriovenous connective tissues
    • Composed of vascular tissue, smooth muscle, and connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue
  • Venous cushions with rich vascular supply 
  • Drain into superior and inferior hemorrhoidal veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins

Epidemiology

  • Worldwide estimated prevalence: 4.4%
  • Prevalence increases with age: peak at 45–65 years old
  • Hemorrhoids affect up to 10 million patients in the United States annually.
    • Upwards of ⅓ of these patients seek medical care. 
    • About 40% of patients are asymptomatic. 
  • No known sex predilection 
  • Present more frequently in:
    • People of higher socioeconomic backgrounds 
    • Those living in rural areas 
    • Caucasian race

Etiology

  • Decreased venous return with increased pressure engorging hemorrhoids: 
    • Straining during defecation 
    • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care-related anatomical compression
    • Aging-related weakening of pelvic support structures 
    • Prolonged sitting on toilet
  • Portal hypertension Portal hypertension Portal hypertension is increased pressure in the portal venous system. This increased pressure can lead to splanchnic vasodilation, collateral blood flow through portosystemic anastomoses, and increased hydrostatic pressure. There are a number of etiologies, including cirrhosis, right-sided congestive heart failure, schistosomiasis, portal vein thrombosis, hepatitis, and Budd-Chiari syndrome. Portal Hypertension with anorectal varices: usually in the midrectum, where portal system and inferior/middle rectal veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins meet
  • Other risk factors:
    • Chronic diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea
    • Constipation 
    • Colon Colon The large intestines constitute the last portion of the digestive system. The large intestine consists of the cecum, appendix, colon (with ascending, transverse, descending, and sigmoid segments), rectum, and anal canal. The primary function of the colon is to remove water and compact the stool prior to expulsion from the body via the rectum and anal canal. Colon, Cecum, and Appendix malignancy
    • Inflammatory bowel disease
    • Obesity Obesity Obesity is a condition associated with excess body weight, specifically with the deposition of excessive adipose tissue. Obesity is considered a global epidemic. Major influences come from the western diet and sedentary lifestyles, but the exact mechanisms likely include a mixture of genetic and environmental factors. Obesity
    • Spinal cord injury
    • Rectal surgery
    • Episiotomy
    • Anal intercourse
External and internal hemorrhoids

Depiction of internal hemorrhoids above the dentate line and external hemorrhoid, likely causing pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, below the dentate line

Image: “Anus with hemorrhoids” by Bruce Blaus. License: CC BY 3.0

Pathophysiology

Pathogenesis

  • Hemorrhoids become symptomatic when enlarged, inflamed, thrombosed, or prolapsed.
  • Hemorrhoidal veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins are located in the submucosal layer in the lower rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal.
    • Arise from a plexus or cushion of dilated arteriovenous channels and connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue 
    • May be external or internally located based on position in relation to dentate line

External hemorrhoids

  • Below the dentate (pectinate) line
  • Arise from the inferior hemorrhoidal plexus
  • Covered by modified squamous epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium with somatic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain receptors 
  • Innervated by pudendal nerve and sacral plexus
  • Acute thrombosis pathogenesis: 
    • Extreme pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain caused by skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin distention and edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema
    • Caused by straining, diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, or constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation 
    • Can persist as excess skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin tags after healing
    • Usually last 7–14 days

Internal hemorrhoids

  • Above the dentate line
  • Unclear pathogenesis; possible theories include:
    • Deterioration of connective tissue Connective tissue Connective tissues originate from embryonic mesenchyme and are present throughout the body except inside the brain and spinal cord. The main function of connective tissues is to provide structural support to organs. Connective tissues consist of cells and an extracellular matrix. Connective Tissue anchoring hemorrhoids 
    • Hypertrophy or increased internal anal sphincter tone 
    • Abnormal arteriovenous distention within hemorrhoidal cushions
    • Abnormal dilation of internal hemorrhoidal venous plexus
  • Not supplied by somatic sensory nerves; usually painless
Anal canal anatomy

Anatomy of the anal canal:
The image shows the pectinate (dentate) line, which marks the area separating the origination of external (below the dentate line ) and internal (above the dentate line) hemorrhoids.

Image by Lecturio.

Clinical Presentation

External hemorrhoids

  • Acutely painful rectal bleeding with associated bowel movement 
  • Perianal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain:
    • Likely from acute thrombosis 
    • Prolapsed or strangulated hemorrhoids 
  • Painful mass at the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal or feeling of fullness 
  • May also have painful, irritated skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin tags (redundant fibrotic skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin) near the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal

Internal hemorrhoids

  • Usually painless, with bright red blood from rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal associated with bowel movement 
  • Can be associated with mucous discharge and itching of perianal skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin 
  • May have associated fecal incontinence and leakage 
  • Wetness or fullness sensation at the perianal area for prolapsed internal hemorrhoid

Diagnosis

Physical examination

  • Best patient position: left lateral decubitus, knees to chest
  • On visual inspection, check for:
    • Fissures, dermatitis, skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin tags, thromboses
    • Intact sensation (anoderm folds and wink)
    • Signs of infection or abscesses
    • Prolapse: bluish and tender mass around the anus
  • On digital rectal exam, check for:
    • Ulcers, masses, tenderness
    • Discharge (e.g., mucus), blood
    • Rectal tone
    • Internal hemorrhoids (palpable when thrombosed)
  • Internal hemorrhoid grading Grading Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis
    • Grade I: prominent hemorrhoidal vessels without prolapse 
    • Grade II: prolapse with Valsalva maneuver with spontaneous reduction
    • Grade III: prolapse with Valsalva maneuver with manual reduction
    • Grade IV: chronically prolapsed with ineffective manual reduction

Laboratory studies and procedures

  • Order CBC if anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview or iron deficiency is suspected.
  • Procedures: 
    • Anoscopy when no hemorrhoid detected on physical exam:
      • Rapid bedside procedure for direct visualization 
      • Evaluate the anal canal and distal rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal.
      • Internal hemorrhoids will appear as bulging purple-blue veins Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins.
      • Thrombosed external hemorrhoids will be acutely tender and have a purple hue.
    • Flexible sigmoidoscopy or colonoscopy based on risk factors for rectal bleeding:
      • Patients > 40 years old with risk factors for colorectal cancer Colorectal cancer Colorectal cancer (CRC) is the 2nd leading cause of cancer-related deaths in the United States. Colorectal cancer is a heterogeneous disease that arises from genetic and epigenetic abnormalities, with influence from environmental factors. Colorectal Cancer 
      • Patients > 50 years old without a colonoscopy within the past 10 years 
      • Unusual rectal bleeding unlikely to be from hemorrhoids

Management

Treatment approach

  • Treat only symptomatic patients.
  • Counsel dietary modifications such as avoiding fatty foods.
  • Distinguish between external and internal hemorrhoids:
    • Visceral innervation of internal hemorrhoids → less pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Somatic innervation of external hemorrhoids → sensitive to pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, thus generally would require surgery with anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts if initial management fails
  • Evaluate for emergency or nonemergency care:
    • Emergency care:
      • Excise acutely thrombosed external hemorrhoid.
      • Instill local anesthetic and create elliptical excision of thrombosed hemorrhoid.
      • If 72 hours or more after onset of symptoms → conservative management
    • Conservative management (for grade I internal and nonthrombosed external hemorrhoids):
      • Warm baths to relax anal sphincter
      • Improve toilet habits with no prolonged sitting.
      • Ice for acute thrombosis
      • Increase dietary fiber and fluid intake.
      • Stool softeners such as docusate sodium
      • Topical analgesics such as lidocaine 
      • Topical corticosteroids 
      • Topical nifedipine and nitroglycerin to relieve anal sphincter spasms

Nonsurgical procedures

The following procedures are for grades I and II internal hemorrhoids that do not respond to conservative management.

  • Rubber band ligation: 
    • Band ligature passed via anoscope; causes tissue necrosis
    • Hemorrhoid sloughs off in 1–2 weeks.
  • Electrocoagulation:
    • Bipolar electrocautery coagulates the hemorrhoid tissue.
    • Excellent control of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain 
  • Sclerotherapy:
    • Indicated for early internal hemorrhoids 
    • Provides chemical sclerosis
    • Higher rate of posttreatment pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and recurrence rates 
    • Not commonly used
  • Cryotherapy: freezing of hemorrhoids 
  • Radiowave and laser ablation with suture ligation:
    • Costly, but effective for prolapsing hemorrhoids 
    • Associated with recurrence

Contraindications:

  • Coagulopathy
  • Portal hypertension Portal hypertension Portal hypertension is increased pressure in the portal venous system. This increased pressure can lead to splanchnic vasodilation, collateral blood flow through portosystemic anastomoses, and increased hydrostatic pressure. There are a number of etiologies, including cirrhosis, right-sided congestive heart failure, schistosomiasis, portal vein thrombosis, hepatitis, and Budd-Chiari syndrome. Portal Hypertension
  • AIDS AIDS Chronic HIV infection and depletion of CD4 cells eventually results in acquired immunodeficiency syndrome (AIDS), which can be diagnosed by the presence of certain opportunistic diseases called AIDS-defining conditions. These conditions include a wide spectrum of bacterial, viral, fungal, and parasitic infections as well as several malignancies and generalized conditions. HIV Infection and AIDS and other immunodeficiency disorders
  • Inflammatory bowel disease (IBD)
  • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-HCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care and immediate postpartum period
  • Large fissure or infection
  • Tumor
  • Prolapse of rectal wall

Surgical treatment

Hemorrhoidectomy:

  • Open approach or minimally invasive laser approach
  • Indicated if other treatments have failed
  • Symptomatic grade III and IV hemorrhoids or severe external hemorrhoids
  • Presence of other local conditions

Other options:

  • Stapled hemorrhoid surgery:
    • For large internal hemorrhoids that are prolapsed 
    • Requires specialized device
  • Doppler-guided transanal hemorrhoidal dearterialization:
    • For grade II prolapsing hemorrhoids 
    • Device identifies and subsequently ligates the blood supply.

Related videos

Differential Diagnosis

  • Anal fissure Anal fissure An anal fissure is a painful superficial tear of the epithelial lining (anoderm) of the anal canal. Anal fissures most often occur secondary to local trauma or irritation from constipation, diarrhea, anal intercourse, or perineal lacerations during childbirth. Anal Fissure: a superficial tear in the anoderm, associated with constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation, trauma, or IBD: Patients present with rectal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain with bowel movements, passage of bright-red blood, and some spasm. Diagnosis is via physical exam and history. Treatment is usually conservative, with increasing fluids and fiber intake, warm sitz baths, and stool softeners. Topical nifedipine helps with anal spasms, and local anesthetics Local anesthetics Local anesthetics are a group of pharmacological agents that reversibly block the conduction of impulses in electrically excitable tissues. Local anesthetics are used in clinical practice to induce a state of local or regional anesthesia by blocking sodium channels and inhibiting the conduction of painful stimuli via afferent nerves. Local Anesthetics provide pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain control. 
  • Acute proctitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the rectal mucosa, can be caused by antibiotics, STDs, and autoimmune GI diseases: Patients can present with anal and rectal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea, abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, mucus discharge, rectal bleeding, and tenesmus. Diagnosis is via history, physical exam, and workup of etiology such as infectious or radiation-induced inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation. Treatment is aimed at symptom control as well as treating the inciting factor. If infection-related, metronidazole is most commonly used. 
  • Colorectal cancer: oncologic process of the colon and/or rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal, with patients usually presenting with painless bleeding from the rectum Rectum The rectum and anal canal are the most terminal parts of the lower GI tract/large intestine that form a functional unit and control defecation. Fecal continence is maintained by several important anatomic structures including rectal folds, anal valves, the sling-like puborectalis muscle, and internal and external anal sphincters. Rectum and Anal Canal with a bowel movement: Colorectal cancer may manifest with weight loss, a rectal mass, abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, and/or anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview. Diagnosis is via clinical presentation, physical exam, colonoscopy, and cross-sectional CT imaging. Treatment is multimodal, with a combination of surgery and chemotherapy based on disease staging Staging Cancer is the 2nd leading cause of death in the US after cardiovascular disease. Many malignancies are treatable or curable, but some may recur. Thus, all malignancies must be assigned a grade and stage in order to guide management and determine prognosis. Grading, Staging, and Metastasis.

References

  1. Bleday, R. (2019). Home and office treatment of symptomatic hemorrhoids. UpToDate. Retrieved February 21, 2021, from https://www.uptodate.com/contents/home-and-office-treatment-of-symptomatic-hemorrhoids
  2. Bleday, R. (2020). Hemorrhoids: Clinical manifestations and diagnosis. UpToDate. Retrieved February 21, 2021, from https://www.uptodate.com/contents/hemorrhoids-clinical-manifestations-and-diagnosis
  3. Perry, K. (2019). Hemorrhoids. Medscape. Retrieved February 21, 2021, from https://emedicine.medscape.com/article/775407-overview

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