Hemorrhoidal disease

Hemoroidi su submukozni vaskularno-vezivni jastučići normalno smješteni iznad nazubljene linije u analnom kanalu te su zaduženi za fiziološku kontinenciju stolice. Normalno, prilikom defekacije se hemoroidi ispupčuju u lumen analnog kanala te kada mehanizam retrakcije zataji i hemoroidi krenu izazivati tegobe, govorimo o hemoroidalnoj bolesti.S obzirom na smještaj u odnosu na nazubljenu liniju, razlikujemo unutarnje, vanjske i mješovite hemoroide. Unutarnji hemoroidi izazivaju tegobe u vidu bezbolnog krvarenja i prolapsa, dok vanjski, koji su smješteni u bogato somatski inerviranom anodermu, zbog tromboze izazivaju snažnu bolnost. Mješoviti imaju karakteristike obaju vrsta hemoroida. Četiri su osnovna mehanizma u patofiziološkom slijedu koji uzrokuju nastanak hemoroidalne bolesti. To su: klizanje analnih jastučića, slabljenje funkcije potpornog vezivnog tkiva, oslabljena venska odvodnja krvi iz sinusoida analnih jastučića te distenzija arteriovenskih anastomoza unutarnjeg hemoroidalnog pleksusa. Rizični čimbenici za nastanak bolesti su svi oni koji rezultiraju kroničnom konstipacijom, što iziskuje veću potrebu za naprezanjem te koji rezultiraju kronično povišenim intraabdominalnim tlakom. Tu spadaju prehrana siromašna vlaknima, uspravan položaj čovjeka, pretilost, ascites, pretjerano vježbanje te napose trudnoća. Pregled pacijenta kod sumnje na hemoroidalnu bolest sastoji se od anamneze i fizikalnog statusa (s posebnim naglaskom na digitorektalni pregled) te anoskopije i po potrebi kolonoskopije (kod rizičnih skupina). Svako liječenje hemoroidalne bolesti treba uključivati konzervativne mjere, tj. promjene životnih i prehrambenih navika. Liječenje niskih stadija bolesti se bazira na minimalnim zahvatima koji se zbog jednostavnosti i kratkog oporavka izvode ambulanto, dok je kirurgija izbor kod: recidiva hemoroida zbog neuspješnog dotadašnjeg liječenja, pacijenata s obilnim krvarenjem te pacijenata s visokim stupnjem hemoroidalne bolesti.Hemorrhoids are submucosal cushions composed of vascular and connective tissue that are normally located in the distal anal canal above the dentate line. The function of hemorrhoid is to ensure continence by closing anal canal after defecation. During defecation, hemorrhoids normally slide down the anal canal, and if afterwards the mechanism of retraction fails, i.e. connective tissue weakens, hemorrhoids start causing difficulties and lead to state called hemorrhoidal disease. Hemorrhoids occur either above or below the dentate line. Internal hemorrhoids occur above the dentate line and patients usually present with painless bleeding and prolapse, whereas external hemorrhoids, located in profusely innervated by cutaneous nerve branches anoderm, are extremely painfull because of thrombosis. Mixed hemorrhoids share characteristics of both, internal and external hemorrhoids. There are 4 main patophysiological mechanisms which intitate the symptomatic hemorrhoidal disease. These are following: the sliding process of the anal cushions, the deterioriation of the connective tissue of the cushion, the reduction of venous return from sinusoids and, finally, the stagnation of blood inside the dilated internal hemorrhoidal plexus. Potential risk factors for the development of symptomatic hemorrhoidal disease are all factors that either lead to chronic constipation, and therefore result in excessive straining during defecation, or to chronically enlarged intraabdominal pressure. Most common risk factors are low fiber diet, human erect position, obesity, ascites, strenuous exercise and pregnancy. The diagnosis of hemorrhoidal disease relies on the history, physical examination with emphasis on proper DRE and additional visual examination that include anoscopy and colonoscopy if necessary. Regardless of severity, treatment almost always should include conservative measures, i.e. introducing high-fiber diet and other lifestyle modifications. Office-based procedures can effectively treat lower grade hemorrhoids, whereas surgery is a method of choice to treat patients with high grade hemorrhoids, those who fail non-surgical treatment and those with profuse bleeding