Histoclinical basis for a new classification of hemorrhoidal disease

TLDR

The current grading of hemorrhoids by size does not reflect disease pathology. The authors propose a new classification of hemorrhoidal disease into bleeding, prolapsing, thrombotic, and mixed types to guide rational treatment. They examined fetal and adult anal canal histology, noting mucosal prominences composed of connective, muscular, vascular, and glandular tissue, and observed degenerative collagen changes and inflammatory reactions in hemorrhoidectomies that likely cause ischemia and thrombosis, supported by a review of 815 patient records. The study found that healthy adults exhibit similar mucosal structures but with degenerative collagen, while hemorrhoidectomies show severe inflammation and ischemia leading to thrombosis and mucosal protrusion, with clinical manifestations of bleeding, thrombosis, prolapse, or mixed presentations.

Abstract

The present classification of first, second, and third grade hemorrhoids only reflects variation in size of a normal human tissue and does not relate to "hemorrhoidal disease." Cross-sections and coronal sections of the anal canal in 32 fetuses, with ages ranging from 28 to 38 weeks of development, were studied and the following fundamental facts were found: in the lumen of the anal canals of fetuses, there are prominences of mucosa formed by conjunctive and muscular tissue, arterial and venous vessels and glands, arranged without following any particular pattern, which resemble similar formations found in the adult that protrude equally in the inside of the canal, known as hemorrhoids. The muscular tissue, smooth or striated, is grouped in bundles, and bunches of collagen fibers of homogeneous, nonfragmented, and regular aspect are found between them. Blood vessels have an ample lumen with a defined structure of collagen tissue as well as muscular tissue in its walls. Prominences of mucosa are connected to the remainder of the intestinal wall by defined conjunctive thick, nonfragmented fibers, that permit firm adherence. In healthy adults, the findings were similar but there was an evident degenerative process in the collagen fibers. In 100 surgical specimens of hemorrhoidectomies, the histologic investigation demonstrated a severe inflammatory reaction that especially affected the blood vessel wall and conjunctive tissue, which probably produced an ischemic lesion of the mucosa that could condition the onset of a vascular thrombosis, allowing displacement of the mucosa and its protrusion through the anus. The files of 815 patients suffering from hemorrhoidal disease were also studied. The main physical findings were bleeding, thrombosis of the internal hemorrhoidal plexus, prolapse of the anal cushions, or a combination of these. The authors propose to classify hemorrhoidal disease as bleeding, prolapsing, thrombotic, and mixed hemorrhoidal disease, aiming toward a rational treatment.