Hemorrhoids, also called piles, are swollen and inflamed veins in your anus and lower rectum. Hemorrhoids may result from straining during a bowel movement or from the increased pressure on these veins during pregnancy, among other causes.
A sometimes embarrassing topic of discussion, hemorrhoids are one of the most common ailments. By age 50, about half of adults have had to deal with the itching, discomfort and bleeding that can signal the presence of hemorrhoids.
Fortunately, many effective options are available to treat hemorrhoids. Most people can get relief from symptoms using home treatments and lifestyle changes.


It is not known why hemorrhoids enlarge. There are several theories about the cause, including inadequate intake of fiber, prolonged sitting on the toilet, and chronic straining to have a bowel movement (constipation). None of these theories has strong experimental support. Pregnancy is a clear cause of enlarged hemorrhoids though, again, the reason is not clear. Tumors in the pelvis also cause enlargement of hemorrhoids by pressing on veins draining upwards from the anal canal.
One theory proposes that it is the shearing (pulling) force of stool, particularly hard stool, passing through the anal canal that drags the hemorrhoidal cushions downward. Another theory suggests that with age or an aggravating condition, the supporting tissue that is responsible for anchoring the hemorrhoids to the underlying muscle of the anal canal deteriorates. With time, the hemorrhoidal tissue loses its mooring and slides down into the anal canal.
One physiological fact that is known about enlarged hemorrhoids that may be relevant to understanding why they form is that the pressure is elevated in the anal sphincter, the muscle that surrounds the anal canal and the hemorrhoids. The anal sphincter is the muscle that allows us to control our bowel movements. It is not known, however, if this elevated pressure precedes the development of enlarged hemorrhoids or is the result of the hemorrhoids. Perhaps during bowel movements, increased force is required to force stool through the tighter sphincter. The increased shearing force applied to the hemorrhoids by the passing stool may drag the hemorrhoids downward and enlarge them.

Signs and symptoms
Signs and symptoms of hemorrhoids may include:

• Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet bowl
• Itching or irritation in your anal region
• Pain or discomfort
• Hemorrhoids protruding from your anus
• Swelling around your anus
• A sensitive or painful lump near your anus
• Leakage of feces

Hemorrhoid symptoms usually depend on the location. Internal hemorrhoids lie inside the rectum. You can't see or feel these hemorrhoids, and they usually don't cause discomfort. But straining or irritation when passing stool can injure a hemorrhoid's delicate surface and cause it to bleed. Occasionally, straining can push an internal hemorrhoid through the anal opening. This is known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.
External hemorrhoids are under the skin around your anus. When irritated, external hemorrhoids can itch or bleed. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus), resulting in severe pain, swelling and inflammation.

How are hemorrhoids diagnosed?

Most individuals who have hemorrhoids discover them in one of several ways. They either feel the lump of an external hemorrhoid when they wipe themselves after a bowel movement, note drops of blood in the toilet bowl or on the toilet paper, or feel a prolapsing hemorrhoid (protruding from the anus) after bowel movements. Severe anal pain may occur when an external hemorrhoid thromboses, or a prolapsing internal hemorrhoid becomes gangrenous. Symptoms of anal discomfort and itching may occur, but anal conditions other than hemorrhoids are more likely to cause these symptoms than hemorrhoids. (Hemorrhoids often get a "bum rap" for such symptoms since both hemorrhoids and other anal conditions are common and may occur together. For example, up to 20% of individuals with hemorrhoids also have anal fissures.)
By the history of symptoms, the physician can suspect that hemorrhoids are present. Although the physician should try his or her best to identify the hemorrhoids, it is perhaps more important to exclude other causes of hemorrhoid-like symptoms that require different treatment. These other causes - anal fissures, fistulae, perianal (around the anus) skin diseases, infections, and tumors - can be diagnosed on the basis of a careful examination of the anus and anal canal. If necessary, scrapings of the anus to diagnose infections and biopsies of the perianal skin to diagnose skin diseases can be done.
External hemorrhoids appear as a bump and/or dark area surrounding the anus. If the lump is tender, it suggests that the hemorrhoid is thrombosed. Any lump needs to be carefully followed, however, and should not be assumed to be a hemorrhoid since there are rare cancers of the perianal area that may masquerade as external hemorrhoids.
The diagnosis of an internal hemorrhoid is easy if the hemorrhoid protrudes from the anus. Although a rectal examination with a gloved finger may uncover an internal hemorrhoid high in the anal canal, the rectal examination is more helpful in excluding rare cancers that begin in the anal canal and adjacent rectum. A more thorough examination for internal hemorrhoids is done visually using an anoscope. An anoscope is a three-inch long, tapering, metal or clear plastic hollow tube approximately one inch in diameter at its viewing end. The anoscope is lubricated and inserted into the anus, through the anal canal, and into the rectum. As the anoscope is withdrawn, the area of the internal hemorrhoid(s) is well seen. Straining by the patient, as if they are having a bowel movement, may make the hemorrhoid(s) more prominent. Anoscopy also is a good way for diagnosing anal fissures.
At times, indirect anoscopy may be helpful. Indirect anoscopy uses a special mirror for visualizing a patient's anus while the patient is seated and straining on a toilet. Indirect anoscopy allows the doctor to see the effects of gravity and straining on the anus. For example, the physician may be able to determine if what is prolapsing is a hemorrhoid, rectal lining, a rectal polyp, or the rectum itself (a condition called procidentia in which the rectum turns inside out and protrudes from the anus).
Whether or not hemorrhoids are found, if there has been bleeding, the colon above the rectum needs to be examined to exclude important causes of bleeding other than hemorrhoids. Other causes include, for example, colon cancer, polyps, and colitis (inflammation of the rectum and/or colon). This examination can be accomplished by either flexible sigmoidoscopy or colonoscopy, procedures that allow the doctor to examine approximately one-third or the entire colon, respectively.

Treatment & Pharmacology

Most of the time, treatment for hemorrhoids involves steps that you can take on your own, such as lifestyle modifications. But sometimes medications or surgical procedures are necessary.
Medications
If your hemorrhoids produce only mild discomfort, your doctor may suggest over-the-counter creams, ointments, suppositories or pads. These products contain ingredients, such as witch hazel or hydrocortisone, that can relieve pain and itching, at least temporarily.
Don't use an over-the-counter cream or other product for more than a week unless directed by your doctor. They can cause side effects, such as skin rash, inflammation and skin thinning.
Minimally invasive procedures
If a blood clot has formed within an external hemorrhoid, your doctor can easily remove the clot with a simple incision, which may provide prompt relief.
For persistent bleeding or painful hemorrhoids, your doctor may recommend another minimally invasive procedure. These treatments can be done in your doctor's office or other outpatient setting.

• Rubber band ligation. Your doctor places one or two tiny rubber bands around the base of an internal hemorrhoid to cut off its circulation. The hemorrhoid withers and falls off within a few days. This procedure — called rubber band ligation — is effective for many people. Hemorrhoid banding can be uncomfortable and may cause bleeding, which might begin two to four days after the procedure but is rarely severe.
• Injection (sclerotherapy). In this procedure, your doctor injects a chemical solution into the hemorrhoid tissue to shrink it. While the injection causes little or no pain, it may be less effective than rubber band ligation.
• Coagulation (infrared, laser or bipolar). These techniques use laser or infrared light or heat. They cause small, bleeding, internal hemorrhoids to harden and shrivel. While coagulation has few side effects, it's associated with a higher rate of hemorrhoids coming back (recurrence) than is the rubber band treatment.

Surgical procedures
If other procedures haven't been successful or you have large hemorrhoids, your doctor may recommend a surgical procedure. Surgery can be performed on an outpatient basis or you may need to stay in the hospital overnight.

• Hemorrhoidectomy. Your surgeon removes excessive tissue that causes bleeding. Various techniques may be used. The surgery may be done with a local anesthetic combined with sedation, a spinal anesthetic or a general anesthetic. Hemorrhoidectomy is the most effective and complete way to remove hemorrhoids, but it also has the highest rate of complications. These may include temporary difficulty emptying your bladder and urinary tract infections related to this difficulty.  Most people experience some pain after the procedure. Medications can be used to relieve your pain. Soaking in a warm bath also helps.
• Stapling. This procedure, called stapled hemorrhoidectomy or stapled hemorrhoidopexy, blocks blood flow to hemorrhoidal tissue. Stapling generally involves less pain than hemorrhoidectomy and allows an earlier return to work. Compared with hemorrhoidectomy, however, stapling has been associated with a greater risk of recurrence and rectal prolapse, in which part of the rectum protrudes from the anus. Talk with your doctor about what might be the best option for you.

Prevention

The best way to prevent hemorrhoids is to keep your stools soft, so they pass easily. To prevent hemorrhoids and reduce symptoms of hemorrhoids, follow these tips:

• Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause hemorrhoids or worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
• Drink plenty of fluids. Drink six to eight glasses of water and other liquids (not alcohol) each day to help keep stools soft.
• Consider fiber supplements. Most people don't get enough of the recommended amount of fiber — 20 to 35 grams a day — in their diet. Studies have shown that over-the-counter fiber supplements, such as Metamucil and Citrucel, improve overall symptoms and bleeding from hemorrhoids. These products help keep stools soft and regular. If you use fiber supplements, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, the supplements can cause constipation or make constipation worse.
• Don't strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum.
• Go as soon as you feel the urge. If you wait to pass a bowel movement and the urge goes away, your stool could become dry and be harder to pass.
• Exercise. Stay active to reduce pressure on veins, which can occur with long periods of standing or sitting, and to help prevent constipation. Exercise can also help you lose excess weight that may be contributing to your hemorrhoids.
• Avoid long periods of standing or sitting. Sitting too long, particularly on the toilet, can increase the pressure on the veins in the anus.

Refrence

1. Hemorrhoids. American Society of Colon & Rectal Surgeons. http://www.fascrs.org/patients/conditions/hemorrhoids. Accessed Dec. 1, 2008.
2. Hemorrhoids. American Gastroenterological Association. http://www.gastro.org/frame-templates/print_template.cfm. Accessed Dec. 1, 2008.
3. Hemorrhoids. National Digestive Diseases Information Clearinghouse. http://digestive.niddk.nih.gov/ddiseases/pubs/hemorrhoids. Accessed Dec. 1, 2008.
4. Kaidar-Person O, et al. Hemorrhoidal disease: A comprehensive review. Journal of the American College of Surgeons. 2007;204:102.
5. Bleday R. Patient information: Hemorrhoids. http://www.uptodate.com/home/index.html. Accessed Nov. 16, 2008.