**4. Pathology and grading**

Hemorrhoids due to prolapse of the anal cushions are called internal hemorrhoids. The lump is covered with mucosa and is often accompanied by the skin of the anal canal, thus forming mixed hemorrhoids, but the predominance is internal hemorrhoids. If only the external hemorrhoidal plexus is dilated, it is called external hemorrhoids. On histological examination of the surgical specimen for internal hemorrhoids, a very marked widening of the vascular plexus and fragmentation of the Treitz muscles will be found. When examined deeply, an increase in leukocytes both inside and outside the blood vessels (inflammatory component) and, with special staining, thinning of the blood vessel walls due to thinning of the tunica media (sphincter-forming muscles) will be seen. External hemorrhoids are mainly dilated subcutaneous veins accompanied by an inflammatory reaction, but patients often present with pain due to a thrombus [2–4].

Stages of internal hemorrhoids need to be determined before starting therapy because the stage will greatly determine the choice of therapy. **Goligher** was the expert who first proposed the degree of hemorrhoids, so the Goligher classification is known, and is still used today (**Figure 1**) [8].

#### **Figure 1.**

*Internal Hemorrhoid grade. Grade I: no prolapse seen from outside, but can be seen by u-turn colonoscopy, Grade II: the lump can be seen during straining and spontaneously return after straining is completed. Grade III: the lump can be seen during and after straining and only by manual help can be reduced to its positions. Grade IV: The lump is already outside the anus, and cannot or fail to be reduced.*
