Hemorrhoids: (Piles)

Presentation

Patients with external hemorrhoids ( Fig. 74.1 ) generally complain of a painful anal lump of sudden onset, which may become intense in severity. This type of pain, in most instances, represents a thrombosed hemorrhoid, which will appear to be purple and is located within the anal canal. It may have been precipitated by straining during defecation, heavy lifting, or pregnancy, but in most cases, there will be no definite preceding event. The external hemorrhoidal swelling is caused by thrombosis of the venous complex. It is very tender to palpation and usually does not bleed unless there is erosion of the overlying skin.

More commonly, patients with internal hemorrhoids ( Fig. 74.2 ) usually seek help because of painless (or nearly painless) bright red bleeding during or after defecation. Patients usually notice intermittent spotting on toilet tissue or blood dripping into the toilet bowl, or both. Blood may be admixed with stool, or blood may appear as streaks on the stool. A prolapsed internal hemorrhoid appears as a protrusion of painless, moist red tissue covered with rectal mucosa at the anal verge. Prolapsed internal hemorrhoids may become strangulated and thrombosed, and thus painful.

Fecal seepage or soiling and a mucoid discharge are most often associated with internal hemorrhoids but may also occur with external lesions. This can cause pruritus, which may be another reason for patients to seek medical care.