Hemorrhoids(piles)
Haemorrhoidal tissues are part of the normal anatomy of the distal rectum and anal canal. They originate either above the dentate line (internal) or below the dentate line (external). It is thought that as the overlying mucosa and skin becomes redundant, especially with straining and constipation, it prolapses into the anal canal. A small amount of prolapse results in bleeding or thrombosis but the patient becomes aware when the prolapse is extensive.
Hemorrhoids may result from straining to move stool. Other contributing factors include pregnancy, aging, chronic constipation or diarrhea, and anal intercourse.
Hemorrhoids are very common in both men and women. About half of the population have hemorrhoids by age 50. Hemorrhoids are also common among pregnant women. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoid vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.
What are the symptoms of hemorrhoids?
Symptoms depend on the severity or degree of the haemorrhoid.
* Grade I painless rectal bleeding internal hemorrhoids don`t prolapse at all.
* Grade II mild discomfort, bleeding internal hemorrhoids drop down with a bowel movement but then pop back up inside spontaneously.
* Grade III pain, bleeding, mucus discharge must be manually pushed back inside the anus.
Grade IV pain, bleeding, possible thrombosis, and strangulation cannot be manually reinserted and are the most severe. Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms and are incorrectly referred to as hemorrhoids.
In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.
Signs
The perineum may appear normal if there is a non-prolapsed internal haemorrhoid. These haemorrhoids are also difficult to feel on digital rectal examination.
The perineum may be macerated from chronic mucus discharge causing local irritation. In 3rd and 4th degree hemorrhoids anal ectropion or perianal protuberance may be there in lax sphincters Proctoscopy may reveal tissue with evidence of chronic venous dilatation, friability, mobility, and squamous metaplasia.
Bluish, soft bulging vessels covered by mucosa may be seen on examination if internal haemorrhoids have prolapsed.
External haemorrhoids, bluish, soft bulging vessels covered by skin .
With external haemorrhoids, bluish, soft bulging vessels covered by skin .
Anal fissure
An anal fissure (fissure-in-ano) is a small, oval shaped tear in skin that lines the opening of the anus. Fissures typically cause severe pain and bleeding with bowel movements. Fissures are quite common in the general population, but are often confused with other causes of pain and bleeding, such as hemorrhoids.
WHAT ARE THE SYMPTOMS OF AN ANAL FISSURE?
The typical symptoms of an anal fissure include severe pain during, and especially after, a bowel movement, lasting from several minutes to a few hours. Patients may also notice bright red blood from the anus that can be seen on the toilet paper or on the stool. Between bowel movements, patients with anal fissures are often relatively symptom-free. Many patients are fearful of having a bowel movement and may try to avoid defecation secondary to the pain.
WHAT CAUSES AN ANAL FISSURE?
Fissures are usually caused by trauma to the inner lining of the anus. Patients with tight anal sphincter muscles (i.e., increased muscle tone) are more prone to developing anal fissures. A hard, dry bowel movement is typically responsible, but loose stools and diarrhea can also be the cause. Following a bowel movement, severe anal pain can produce spasm of the anal sphincter muscle, resulting in a decrease in blood flow to the site of the injury, thus impairing healing of the wound. The next bowel movement results in more pain, anal spasm, decreased blood flow to the area, and the cycle continues. Treatments are aimed at interrupting this cycle by relaxing the anal sphincter muscle to promote healing of the fissure.
Other, less common, causes include inflammatory conditions and certain anal infections or tumors. Anal fissures may be acute (recent onset) or chronic (present for a long period of time). Chronic fissures may be more difficult to treat, and may also have an external lump associated with the tear, called a sentinel pile or skin tag, as well as extra tissue just inside the anal canal (hypertrophied papilla) .
Hypertrophied Papillae
At times a movable mass can be palpated in the anal area and, on anoscopic examination, a thickened anal papilla is visualized at the dentate line. This can be confused with a polyp. Hypertrophied papillae are generally white, firmer on digital examination than polyps, and located at the dentate line (Figure 12). Treatment is generally not indicated for confirmed hypertrophied papillae.
Hypertrophied papilla (arrow). A hypertrophied papilla can often be palpated and confused with a polyp. Anoscopy can confirm the true nature of the lesion. If diagnosis is uncertain, biopsy or removal is indicated