Snap Shot A 54-year-old female with a history of alcohol abuse presents with complaints of a mass in his anus. Introduction Engorgement of venous plexus derived from: superior hemorrhoid vein (internal hemorrhoids) inferior hemorrhoid vein (external hemorrhoids) Predisposing factors include: pregnancy straining at stool constipation cirrhosis with portal hypertension causes anorectal varices not to be confused with hemorrhoids Thrombosed external hemorrhoid not a true hemorrhoid caused by subcutaneous external hemorrhoids of anal canal Classified by degree: 1st degree: does not prolapse 2nd degree: prolapses with defecation, spontaneously reduces 3rd degree: polapses with defecation, requires manual reduction 4th degree: can not be reduced Presentation Internal hemorrhoids Anal mass / prolapse Bleeding External hemorrhoids (below dentate line) pain itching bleeding Thrombosed external hemorrhoid excruciating pain with history of hemorrhoids bluish elevation of skin Evaluation Rectal exam, anoscope, sigmoidoscopy Treatment Conservative treatment: proper dietary (fiber) and bowel habits sitz bath stool softeners cortisone cream Definitive Treatment banding cryosurgery sclerotherapy laser surgery hemorrhoidectomy for large refractory hemorrhoids contraindicated in Crohns disease Thrombosed external hemorrhoids sitz baths stool softeners or in severe cases excision of skin with evacuation of the thrombus Prognosis, Prevention, and Complications Exsanguination (may not have signs of external bleeding) Pelvic infection Incontinence Thrombosis Strangulation Ulceration Infection Anal fissures