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Hemorroidas: Causas, Sintomas, Graus e Opções de Tratamento

Hemorroidas são almofadas vasculares normais no canal anal que se tornam sintomáticas quando inchadas, inflamadas ou prolapsadas. Elas são classificadas como internas (acima da linha dentada, inervação visceral → tipicamente indolores) ou externas (abaixo da linha dentada, inervação somática → frequentemente dolorosas).

Fatores de Risco e Etiologia

• Constipação crônica e esforço (aumento da pressão intra-abdominal, congestão venosa)
• Diarreia crônica (irritação, defecação frequente)
• Gravidez: Compressão uterina da veia cava inferior → hipertensão venosa pélvica; relaxamento venoso induzido por progesterona; esforço no parto
• Obesidade (aumento da pressão intra-abdominal)
• Envelhecimento: frouxidão do tecido conjuntivo, redução do tônus vascular
• Sentar prolongado ou tempo no vaso sanitário (leitura, uso de telefone)
• Levantamento de peso pesado e manobras de Valsalva
• Dieta pobre em fibras

Sintomas por Tipo e Grau

Internal (Graded I–IV)	External
Grade I: Bleeding only (bright red, painless)	Perianal swelling, pain (thrombosis)
Grade II: Prolapse with strain, spontaneous reduction	Skin tags (residual)
Grade III: Prolapse requiring manual reduction	Hygiene difficulty, pruritus
Grade IV: Irreducible prolapse (strangulation risk)	Acute thrombosis: severe pain, bluish lump

Conservative Management (First-Line for Grades I–II)

• Fiber supplementation: Psyllium 10–20 g/day → soft, bulky stool
• Hydration: 2–3 L water/day
• Toilet habits: Limit time (<5 min), avoid straining, use a footstool (squatty potty)
• Topical OTC: Hydrocortisone 1% (≤1 week), witch hazel, lidocaine, phenylephrine
• Sitz baths: Warm water 10–15 min, 2–3×/day
• Stool softeners: Docusate (less effective than fiber)
• Weight loss and exercise

Office-Based Procedures (Grades I–III)

• Rubber band ligation (RBL): Gold standard for Grades I–III; band cuts off blood supply → necrosis/sloughing in 7–10 days. Success 70–90%.
• Sclerotherapy: 5% phenol in oil injected → fibrosis. Good for Grade I–II, anticoagulated patients.
• Infrared coagulation (IRC): Heat → sclerosis. Less effective than RBL.
• Bipolar diathermy / laser

Surgical Options (Grade III–IV, Failed Office Treatment)

• Excisional hemorrhoidectomy (Milligan-Morgan, Ferguson): Gold standard for severe disease; 95% cure; significant postoperative pain for 1–2 weeks.
• Stapled hemorrhoidopexy (PPH): Mucosal prolapse resection and fixation; less pain, higher recurrence.
• Doppler-guided hemorrhoidal artery ligation (DG-HAL): Suture ligation of feeding arteries; less pain, variable efficacy.

Thrombosed External Hemorrhoid

• ≤72 hours: Excision under local anesthesia (complete clot removal) → immediate relief.
• >72 hours: Conservative management (pain resolves in 7–10 days; skin tag may remain).

Red Flags (Refer Immediately)

• Rectal bleeding in patients >50 years or with risk factors → colonoscopy (rule out colorectal cancer)
• Change in bowel habits, weight loss, anemia
• Severe pain, urinary retention, signs of sepsis