Hemorrhoidal disease has accompanied mankind since its beginning.

HEMORRHOIDAL DISEASE

Hemorrhoidal disease has accompanied humanity since its beginnings, apparently secondary to bipedalism, since no quadruped suffers from this condition, and from the earliest medical writings, specifically in the Ebers Papyrus, reference is made to this pathology, with the common denominator of having always been vilified and underestimated throughout history. Despite the above, the hemorrhoidal plexuses have important functions, which include: as vascular cushions they protect the anal sphincters from being injured during the passage of stool, they also secrete mucus which lubricates the feces reducing friction and finally they guarantee the hermetic closure of the anus contributing to fecal continence. 

ANATOMY:

The hemorrhoidal folds are present from birth and consist of three components: mucosa, a lax areolar tissue rich in collagen fibers associated with abundant blood vessels and a supporting tissue provided by the internal anal sphincter. 

There is a popular belief that hemorrhoids are veins; however, they are not, since they lack a muscular layer, nor are they arteries, as they do not have an adventitial layer, yet their bleeding is bright red, pulsatile and has an arterial pH. For the above reasons, histologically hemorrhoids are vascular sinusoids which, when injured, bleed from the presinusoidal arteries.

The three main hemorrhoidal folds whose growth is above the dentate line; they are aligned two to the right (one anterior, one posterior) and one left lateral, which according to the hands of the clock are at 2, 5 and 9 o'clock.

ETIOLOGY:

Although all individuals possess hemorrhoidal plexuses, not all develop hemorrhoidal disease. This condition occurs after enlargement or hypertrophy of these cushions, becoming symptomatic when they bleed and prolapse with straining. The proposed etiological factors include, among others: constipation, prolonged straining, pregnancy and anal sphincter injury, etc. All of these conditions favor distension and rupture of the collagen fibers of the loose areolar tissue with the consequent dilation of the vascular sinusoids, making them more susceptible to injury from solid stool and to bleeding.  

CLASSIFICATION:

For anatomical and clinical considerations hemorrhoidal disease has been divided into external hemorrhoids and internal hemorrhoids.

External hemorrhoids are located below the pectinate line at the level of the anal orifice, being covered by squamous epithelium and innervated by somatic nerve endings and therefore are sensitive to touch, temperature, stretching and pain. They may be confused with skin tags (marisca, papillae, etc.) which are ridges or stretches of skin at the level of the anal orifice.

Internal hemorrhoids are located proximal to the dentate line and are covered by transitional or columnar epithelium. They are classified according to the degree of prolapse with respect to the anal orifice.

                        Grade I:  Protruyen dentro del canal anal pero no sobrepasan el orificio anal.

                        Grade ll:  They protrude through the anal orifice with valsalva maneuver or by defecatory effort but reduce spontaneously.

                        Grade lll:  They protrude through the anal orifice with or without defecatory effort and require manual reduction.

                        Grade lV:  Permanently prolapsed and do not reduce

It is the latter, grade IIl and IV hemorrhoids that have the greatest possibility of complications such as strangulation and gangrene.