Ihe anorectal area is drained by the internal and external hemorrhoidal venous systems. Ihe internal hemorrhoidal veins, which in essence are submucosal vascular cushions that may contribute to anal continence, are located proximal to the dentate line and drain into the portal system through the superior rectal veins and the inferior mesenteric vein. Ihey also communicate freely with the external hemorrhoidal veins, which are subcutaneous to the anoderm and drain primarily through the pudendal and iliac venous systems. When these hemorrhoidal plexuses become excessively engorged, prolapsed, or thrombosed, they are referred to as hemorrhoids—one of the most common problems afflicting human beings.
Internal hemorrhoids, which course along the terminal branches of the superior rectal artery, are constant in their location, coursing longitudinally at the right posterolateral, right anterolateral, and left lateral positions (at the 2-, 5- and 9-o'clock positions when the patient is viewed prone) ( Fig 78-2). Internal hemorrhoids are not readily palpable and can best be visualized through an anoscope. External hemorrhoids are dilatation of veins at the anal verge and can be seen at external inspection.
Although the cause of enlarged hemorrhoids is not always known, there is an association with constipation and straining at stool. Ihey are prevalent during pregnancy and may be the result of sustained increased pressure on the venous drainage of the rectum. One of the physiologic shunts of the portal system involves the hemorrhoidal veins. Consequently, increased portal pressure, occurring as a result of chronic liver disease, may produce marked dilatation and varix formation of the hemorrhoids. Ihe bleeding that can result is extremely difficult to control.
Iumors of the rectum and sigmoid colon, often associated with constipation, tenesmus, and incomplete evacuation, may cause hemorrhoids and must be ruled out in all cases of rectal bleeding in patients over the age of 40.
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