-          according to the classical concept, these are varicosely dilated veins of the haemorrhoidal plexuses (external haemorrhoidal plexus - in the subcutaneous area of the anal region, internal haemorrhoidal plexus - under the mucous membrane of the zona haemorhoidalis inside from the m. sphincter ani internus)

-          more precisely, it is a cluster of blood vessels (arterioles, venules and their connections), connective tissue and smooth muscle, which is present from birth and enlarges under certain circumstances

-          the outer ones are from the ectoderm and thus covered by squamous epithelium and innervated from the n. pudendalis, the inner ones from the endoderm of the GIT and without sensory innervation. Painful is only inflammation in the surrounding area.

-          internal haemorrhoids have predilection 3,7,11. Most often anterior right quadrant. The outer ones are without predilection

complications

-          the main complications are inflammation and thrombosis (affecting both external and internal haemorrhoids, which can erupt outwards), or incarceration of the erupted node and its gangrene; chronic bleeding leads to anaemia.

-          untreated thrombosis regresses on its own in about 14 days, so if the patient comes in late and the pain diminishes, incision is not necessary. But then the recurrence rate is 50%.

-          rare condition of acute haemorhoidal crisis - complete prolapse with reflex spasm and subsequent thrombosis. Requires acute surgical intervention.

classification

1.)   external haemorrhoids – nodules around the anus, externally visible

2.)   intermedial haemorrhoids – connections between inner and outer plexus

3.)   internal haemorrhoids – nodules inside the rectum, about 4 cm from anal opening, typically in positions 3, 7, 11, each node is accessed by a terminal artery - bright red blood when bleeding

I. grade – only manifestation is bleeding

II. grade – prolapse of the node during stool (increased intra-abdominal pressure), loosening of the abdominal press spontaneously repairs

III. grade – node prolapse during standing and walking, manually repairable

IV. grade – permanent prolapse, not fully repairable

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clinical manifestations and diagnosis of haemorrhoids

-          internal haemorrhoids do not hurt, they are manifested by pressure and bleeding (rectorrhagia - fresh, bright red blood on or after stool), which is usually small and permanent, leading to anaemia, rarely massive, pain occurs with complications (inflammation, thrombosis, eruption)

-          external haemorrhoids are manifested by pain on stool and itching from irritation of the surrounding skin

-          in the rest period, haemorrhoids are pink, elastic and painless; thrombosis is manifested by painful swelling and blueness of the nodule, inflammation by pain and redness

-          examination of haemorrhoids requires inspection of the anal area, per rectum examination, ano-/rectoscopy and possibly coloscopy and irrigography

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differential diagnosis:

-          colorectal or anal carcinoma or polyp

-          colitis ulcerosa, m. Crohn

-          diverticulitis

-          fissura ani

-          rektal prolapsus

treatment

1.)   conservativ – first choice for stages I and II.

 -          anal hygiene, regimen (regular defecation, not sitting for long periods of time, physical activity), diet (enough fiber, not taking spices), sedentary baths or compresses (chamomile, oak bark ...)

-          suppositories and ointments (astringents, haemostatics, local anaesthetics, spasmolytics, antiphlogistics including corticosteroids, ATBs)

-          in inflammation and thrombosis, bed rest in the prone position and cold compresses with ATB

2.)   surgical

 -          in case of inflammation and thrombosis - under local anesthesia incision and expression of the thrombus

-          st. I and II - sclerotisation (injection of phenol or aethoxysclerol), laser treatment, IR photocoagulation, Baron's ligature

-          st. III and IV - surgical stapler operation or classical operation according to Whitehead)

postoperative complications:

-          mucous ectropium (wet anus feeling) - new operation

-          stenosis (excessive mucosal excision) - gradual dilatation

-          incontinence (sphincter violation) - sphincter reconstruction