Pathophysiology of hemorrhoidal disease and approach to its management

Hemorrhoids are a very common anorectal disorder defined as the symptomatic enlargement and abnormally downward displacement of anal cushions. Hemorrhoids become pathognomonic due the degenerative change of supportive tissue within the anal cushions, vascular hyperplasia, and hyperperfusion of hemorrhoidal plexus. Early grades of hemorrhoids (Grade I and 2) can be effectively treated with dietary and lifestyle modification, pharmacological treatment, and different office-based procedures. Surgical intervention is indicated in symptomatic and advanced grades of hemorrhoids. Although hemorrhoidectomy is still considered as the gold standard, more recently, newer approaches like Ligasure and ultrasonic hemorrhoidectomy, stapled hemorrhoidopexy, and doppler-guided hemorrhoidal artery ligation have been used with a desirable success. However, post-procedural pain and disease recurrence remain the most challenging problems. This article deals with the pathophysiology and evidence based approach to hemorrhoidal diseases.