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Hemorrhoids are considered a normal component of the anorectal anatomy. The terms hemorrhoids (also haemorrhoids, piles) and hemorrhoidal disease actually refer to the pathological state of symptoms attributed to the abnormalities in the anal canal.
Anatomy of the hemorrhoids
The hemorrhoids have their own physiological function and there are several hypotheses about it. Most commonly it is believed that the internal hemorrhoids contribute towards maintaining fecal continence. This is very important, given that patients who suffer from hemorrhoidal disease often seek to remove the hemorrhoids. Piles are composed predominantly of vascular tissue contained within the submucosal space of the anal canal. These cushions are supported by smooth muscle and connective tissue. The smooth muscle is also known as Treitz’s muscle. It’s contained inside the hemorrhoidal cushion. These muscle fibers have a supportive function, they are there to keep the hemorrhoids fixed to the walls of the internal sphincter. The hemorrhoids are supplied with blood via the inferior mesenteric artery and its branches. The three main branches (superior, middle and inferior) are not constantly presented, their localization differs from person to person.
It has been proven that the blood within the cushions is more arterial than venous, which is why patients are complaining from bright red blood on the toilet paper or in the bowl. Recent studies have shown that in patients, who suffer from a hemorrhoidal disease, the superior rectal artery has enlarged diameter and greater blood flow.
Prevalence of the hemorrhoidal disease
Despite the fact that hemorrhoids are normal structures of the anorectum, the hemorrhoidal disease presents a major challenge for both patients and medical professionals. There are different estimates of the prevalence of symptomatic hemorrhoidal disease, but the numbers usually move in a range between 5-30% of the population. However, many are reluctant to seek treatment, thus the real prevalence of the hemorrhoidal disease is largely unknown.
Hemorrhoids are the most common causes of anal pathology in practice. Patients who suffer from any anorectal discomfort tend to “blame” the hemorrhoids. And although it is true, that hemorrhoids are the main cause for a large portion of the anorectal complaints, it is appropriate to seek medical help, in order to rule out more serious conditions.
Classification of hemorrhoids
Most people are not aware that piles are classified according to their anatomic origin. Thus we have internal and external hemorrhoids. Internal hemorrhoids originate proximal to the linea dentata (also known as the pectinate line). External hemorrhoids are located outside of the anal canal, they develop from ectoderm and are covered with epithelium, whereas the internal hemorrhoids are derived from embryonic endoderm and are lined with the epithelium of the anal mucosa.
The general classification might cause some confusion in patients who have no previous experience with the hemorrhoidal disease. Sometimes patients feel that their piles are located outside of the anal verge, but in fact, they originate from the inside. In this case, we are talking about a prolapse of the internal hemorrhoidal tissue. It’s also important to note, that you can develop both internal and external hemorrhoids. To address the degree of prolapse of the internal hemorrhoids, we use a fourth-degree system (presented in the table below).
Classification of the internal hemorrhoids
- Grade I | The hemorrhoids do not prolapse, but they bulge inside the anal canal. Patients will usually complain from bleeding and occasional flare-ups.
- Grade II | The hemorrhoids prolapse during defecation, but spontaneously reduce. Bleeding during defecation might be more pronounced.
- Grade III | The hemorrhoids prolapse during defecation and must be manually reduced. Patients will usually complain from bleeding, itching, soiling of the underwear.
- Grade IV | The hemorrhoids are prolapsed and cannot be reduced. In this stage, the hemorrhoids could severely hurt the quality of life.
This classification has its shortcomings. It does represent the degree of severity of the hemorrhoidal disease, but it doesn’t reflect the degree of discomfort for the patient. In some cases, the internal hemorrhoids could be several or very large, but without prolapsing. Nevertheless, they might cause serious anal discomfort, itching or even bleed.