HEMORRHOID

Patofisiology
Today, the theory of sliding anal canal lining is widely accepted[6]. This proposes that hemorrhoids develop when the
supporting tissues of the anal cushions disintegrate or deteriorate. Hemorrhoids are therefore the pathological term to describe
the abnormal downward displacement of the anal cushions causing venous dilatation. There are typically three major anal
cushions, located in the right anterior, right posterior and left lateral aspect of the anal canal, and various numbers of minor
cushions lying between them
The anal cushions of patients with hemorrhoids show significant pathological changes. These changes include abnormal
venous dilatation, vascular thrombosis, degenerative process in the collagen fibers and fibroelastic tissues, distortion and
rupture of the anal subepithelial muscle.
In addition to the above findings, a severe inflammatory reaction involving the vascular wall and surrounding connective tissue
has been demonstrated in hemorrhoidal specimens, with associated mucosal ulceration, ischemia and thrombosis
Causes
Common causes:

Hemorrhoidal bulging and distension into the lumen of the anal canal results from deterioration of connective tissue
that supports hemorrhoids and occurs as a normal part of aging
Conditions that increase intraabdominal pressure may accelerate deterioration of supporting connective tissue and
prolapse of the anal canal, which is known as the sliding anal canal theory. Vessels become distended as they lose
support

Serious causes:

Any cause of portal hypertension such as cirrhosis can worsen hemorrhoidal vein pressure. A misconception is that
rectal varices are a cause of hemorrhoidal disease. In patients with liver disease, varices may occur because of the
dual blood supply to the rectum. When viewed endoscopically, rectal varices occur in the rectum and hemorrhoids are
located in the anus. In such cases, treatment of the liver disease and portal system decompression is the primary goal

Risk factors

Increased abdominal pressure as a result of ascites or pregnancy

Diarrhea
Pregnancy
Childbirth is associated with thrombosed and prolapsed hemorrhoids
Heavy lifting
Prolonged sitting
Conditions resulting in Valsalva maneuver such as chronic cough, straining related to constipation, or prostatism
Anal intercourse

Differential Diagnosis