Hemorrhoids

hemorrhoids

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What are hemorrhoids?

Hemorrhoids are swollen and inflamed veins around the anus or in the lower rectum. The rectum is the last part of the large intestine leading to the anus. The anus is the opening at the end of the digestive tract where bowel contents leave the body.

There are two types of hemorrhoids:

External hemorrhoids:

External hemorrhoids are located at the anal opening, just beneath the skin. These tissues rarely cause problems unless they thrombose (form a blood clot). When this occurs, a hard, bluish lump may appear. A thrombosed hemorrhoid also causes sudden, severe pain. In time, the clot may go away on its own. This sometimes leaves a “skin tag” of tissue stretched by the clot.

Internal hemorrhoids:

Internal hemorrhoids often occur in clusters around the wall of the anal canal. They are usually painless. But they may prolapse (protrude out of the anus) due to straining or pressure from hard stool. After the bowel movement is over, they may then reduce (return inside the body). Internal hemorrhoids often bleed. They can also discharge mucus.

Grading Hemorrhoids

Based on the physical exam, your doctor may assign a grade to internal hemorrhoids. The grades are based on the severity of your symptoms.

Grades of Hemorrhoids

• Grade I hemorrhoids do not protrude from the anus. They may bleed, but otherwise cause few symptoms.
• Grade II hemorrhoids protrude from the anus during bowel movements. They reduce back into the anal canal when straining stops.
• Grade III hemorrhoids protrude on their own or with straining. They do not reduce by themselves, but can be pushed back into place.
• Grade IV hemorrhoids protrude and cannot be reduced at all. They can also be painful and may require prompt treatment.

History of Hemorrhoids

The earliest known mention of this affliction transpired in Babylon round about ~2250 BC which described the symptoms of hemorrhoids in the Code of King Hammurabi.

Interestingly, the first recorded incidence of hemorrhoids occurred in Egypt in 1700 BC.  Written on papyrus treatment emphasized a topical wound ointment of great protection.

And remarkably, the use of the word “haemorrhoids” in English was in 1398, principally as a derivative from Old French termed “emorroides”, taken from Latin derivative “hæmorrhoida-ae”, which in turn was taken from the Greek “αἱμορροΐς” or translated haimorrhois.

Celsus (25 BC – AD 14) described ligation and excision procedures, and discussed the possible complications. In the 13th century, European surgeons such as Lanfranc of Milan, Guy de Chauliac, Henri de Mondeville, and John of Ardene made great progress and development of the surgical techniques.

Epidemiology and prevalence

Worldwide, the prevalence of symptomatic hemorrhoids is estimated at 4.4% in the general population. In the United States, up to one third of the 10 million people with hemorrhoids seek medical treatment, resulting in 1.5 million related prescriptions per year. The number of hemorrhoidectomies performed in US hospitals is declining. A peak of 117 hemorrhoidectomies per 100,000 people was reached in 1974; this rate declined to 37 hemorrhoidectomies per 100,000 people in 1987. Outpatient and office treatment of hemorrhoids account for some of this decline.

Patients presenting with hemorrhoidal disease are more frequently white, from higher socioeconomic status, and from rural areas. There is no known sex predilection, although men are more likely to seek treatment. External hemorrhoids occur more commonly in young and middle-aged adults than in older adults. The prevalence of hemorrhoids increases with age, with a peak in persons aged 45-65 years.

What causes and risks makes hemorrhoids?

Swelling in the anal or rectal veins causes hemorrhoids. Hemorrhoid symptoms are similar to the symptoms of other anorectal problems, such as fissures, abscesses, warts, and polyps.  Several factors may cause this swelling, including:

• Chronic constipation or diarrhea
• Straining during bowel movements
• Sitting on the toilet for long periods of time
• Strenuous exercise or heavy lifting
• A lack of fiber in the diet
• Heredity
• Spinal cord injury
• Loss of rectal muscle tone
• Rectal surgery
• Episiotomy
• Anal intercourse
• Colon malignancy
• Hepatic disease
• Obesity
• Faulty bowel function due to overuse of laxatives or enemas
• Straining during bowel movements
• Another cause of hemorrhoids is the weakening of the connective tissue in the rectum and anus that occurs with age
• Pregnancy can cause hemorrhoids by increasing pressure in the abdomen.

What are the symptoms of hemorrhoids?

• The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement.
• Internal hemorrhoids that are not prolapsed are usually not painful.
• Prolapsed hemorrhoids often cause pain, discomfort, and anal itching.
• Blood clots may form in external hemorrhoids. A blood clot in a vein is called a thrombosis.
• Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus.
• When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch.
• Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse.
• Hemorrhoids are not dangerous or life threatening.
• Symptoms usually go away within a few days, and some people with hemorrhoids never have symptoms.

Complications

• Iron-deficiency anemia, if blood loss is significant.
• Severe pain caused by a blood clot in a hemorrhoid.
• Infection or ulceration of a hemorrhoid.

How are hemorrhoids diagnosed?

The doctor will examine the anus and rectum to determine whether a person has hemorrhoids. The doctor will perform a physical exam to look for visible hemorrhoids.

1. A visual exam is used to view the outer anal skin.
2. A digital rectal exam is used to check for hemorrhoids or other problems in the anal canal. It is done using a lubricated gloved finger.
3. An anoscopic exam is done using a special viewing tube called an anoscope. The scope helps your doctor view the anal canal.

Additional exams may be done to rule out other causes of bleeding, especially in people age 40 or older:

Colonoscopy. A flexible, lighted tube called a colonoscope is inserted through the anus, the rectum, and the upper part of the large intestine, called the colon. The colonoscope transmits images of the inside of the rectum and the entire colon.

Sigmoidoscopy. This procedure is similar to colonoscopy, but it uses a shorter tube called a sigmoidoscope and transmits images of the rectum and the sigmoid colon, the lower portion of the colon that empties into the rectum.

Barium enema x ray. A contrast material called barium is inserted into the colon to make the colon more visible in x-ray pictures.

How to treat and cure hemorrhoids?

Home remedies

• Over-the-counter topical treatments, such as hydrocortisone or hemorrhoid cream, can ease your discomfort from hemorrhoids.
• Soaking your anus in a sitz bath for 10 to 15 minutes per day can also help.
• Practice good hygiene by cleaning your anus with warm water during a shower or bath every day.
• But don’t use soap, as soap can aggravate hemorrhoids. Also avoid using dry or rough toilet paper when you wipe after a bowel movement.
• Using a cold compress on your anus can help reduce hemorrhoid swelling.
• Pain relievers, such as acetaminophen, ibuprofen, or aspirin can also alleviate the pain or discomfort.

Non operative managements

The most common surgical treatments are ligation or tissue destruction, fixation techniques (i.e., hemorrhoidopexy), and excision (i.e., hemorrhoidectomy).

Rubber band ligation

Rubber band ligation is a common office treatment for internal hemorrhoids and is often recommended as the initial surgical treatment for grades 1 to 3 hemorrhoids. The procedure involves placing a rubber band around a portion of redundant anorectal mucosa. This causes strangulation of the blood supply to the hemorrhoid, resulting in tissue necrosis and sloughing of the hemorrhoid in five to seven days.

Rubber band ligation

The procedure is performed through an anoscope, and a variety of devices are available to apply the bands. Because the bands are placed in the insensate region (above the dentate line), the procedure can be performed without anesthesia.

Stapled hemorrhoidopexy

Stapled hemorrhoidopexy is an alternative treatment for grades 2 to 4 hemorrhoids. The device removes a circumferential column of mucosa and submucosa immediately above the hemorrhoids, thus interrupting the blood supply. The ring of staples fixes the downwardly displaced vascular cushions back into their original locations to restore anatomy and function.

Postoperatively, patients have a circular staple line above the dentate line, which becomes buried within the mucosa over time. Staples can be noted within the rectum for many months after the procedure and can cause rectal bleeding. Compared with excisional hemorrhoidectomy, stapled hemorrhoidopexy is more favorable in terms of postoperative pain, time until return to work, and complications of pruritus and fecal urgency

Sclerotherapy

Sclerotherapy for hemorrhoids is a less-invasive, less-painful procedure that causes the problematic hemorrhoid to shrivel and dissipate within a short period of time. Sclerotherapy usually is successful, but it is not a permanent solution and might need to be repeated, and there is a chance of fairly heavy bleeding. Five percent phenol in almond oil is injected in submucosa just above the base of hemorrhoid causing inflammation and scarring. It is an OPD procedure but complications like prostatitis and sepsis can occur.

IR coagulation and Sclerotherapy

Infrared coagulation

Infrared coagulation involves the application by a polymer probe tip of radiation from a tungsten-halogen lamp to the base of the hemorrhoid. This creates an ulcer that subsequently heals, producing cicatrisation (scarring) that reduces blood flow to the hemorrhoid. The procedure is well tolerated, but success rates are lower than those with rubber band ligation. Infrared coagulation may be considered in patients who are on anticoagulant therapy

Bipolar Diathermy

Bipolar diathermy for hemorrhoid uses electric current of very high frequency. The electrical energy is then used to thicken the affected tissue. Bipolar diathermy for hemorrhoid may just require several sessions before one could get rid of all the piles though.

Cryotherapy

Cryotherapy is based on the concept that freezing the internal hemorrhoid at low temperatures can lead to tissue destruction. A special probe is used, through which nitrous oxide at −60° to −80°C or liquid nitrogen at −196°C is circulated. The procedure is time consuming and associated with a foul-smelling profuse discharge, irritation and pain. The procedure is no longer recommended for the treatment of internal hemorrhoids.

Operative managements

Excisional hemorrhoidectomy

In excisional hemorrhoidectomy, an elliptical incision is made over the hemorrhoidal complex, which is then mobilized from the underlying sphincter and excised. The wound is closed with sutures.

Several randomized controlled trials (RCTs) and meta-analyses have shown that excisional hemorrhoidectomy is the most effective treatment to reduce recurrent symptoms in patients with grade 3 or 4 hemorrhoids. It is also recommended for patients with mixed hemorrhoids and for those with recurrent hemorrhoids in whom other treatments have been ineffective.

Doppler-guided Hemorrhoidal Artery Ligation

It involves a proctoscope with a Doppler transducer integrated in the probe allowing sequential identification of the position and depth of superior rectal arterial branches (usually 5-7 are found at one level), which are then selectively ligated 2-3 cm above the dentate line at two levels 1-1.5 cm apart by absorbable sutures via a lateral ligation window within the scope. The interference with the blood supply suppresses the bleeding and volume of the hemorrhoids and symptomatic relief is usually evident within 6-8 weeks.

Prevention

• The key to prevention is proper diet and habits to produce softer stools, thus reducing the need to strain.
• Add plenty of fiber to diet (fruits, vegetables, legumes, and whole grains).
• Good dietary fiber sources include:

1. Whole wheat
2. Brown rice
3. Oatmeal
4. Pears
5. Carrots
6. Buckwheat
7. Bran

• Dietary fiber helps create bulk in the intestines, which softens the stool, making it easier to pass.
• Drink plenty of fluids (8 to 10 glasses of water daily).
• Don’t hurry or strain to push bowel movements, but avoid prolonged toilet sitting.
• Avoid vigorous wiping after bowel movements (to decrease irritation).
• Lose weight, if overweight.
• Exercise regularly.