Hemorrhoids are dilated and congested vascular complex at the lower end of the anal canal, Think of them as varicose veins. They are highly vascular “cushions” or “pads” consisting of discrete masses of thick sub mucosa which contain blood vessels, smooth muscle, and elastic and connective tissues. Such cushions are present in everyone and the term “hemorrhoids” is confined to situations in which these cushions are enlarged, inflamed and cause symptoms.
The Rectum is the 10-15 cm of the lower colon above the dentate line. In the rectal ampulla, a space above the dentate line, there are three vascular hemorrhoidal cushions which help the muscles to maintain continence. No pain fibers here. The dentate line separates the zone of internal hemorrhoids above from the zone of external hemorrhoids below. The anal canal is the 3-4 cm between the dentate line and anal verge. The nerves in this area help us with continence to discriminate between gas, fluid and solid waste. Anus or anal verge is the outlet covered by true skin rich in nerve endings. Internal hemorrhoids are above the dentate line and covered with insensitive mucosa while externals are below the dentate line and covered by sensitive skin-like cells. If the outer aspect of a hemorrhoid is covered with skin but the inner side is mucosa
Over half the population will have some occurrence of hemorrhoid symptoms by age 50 and the incidence peaks between 45 and 65. Men and women affected equally, but men are more likely to seek treatment. Ten to twenty million Americans have active hemorrhoids and as many as 5 million seek medical help each year. We spend over 250 million dollars each year on hemorrhoid products. 1.5 million Prescriptions. More than 120,000 surgical hemorrhoidectomies are done each year. Most are unnecessary. 1.5 million Colonoscopies are done each year.
One of the main causes of getting hemorrhoids is not enough soluble fiber in your diet.
The causes of hemorrhoids is a lack of soluble fiber and not enough water in the diet, straining, and sitting longer than 2 minutes on the toilet which promotes prolapse of the anal cushions. Hemorrhoids may be inherited, but it may only be the behaviors and diet habits that are passed along. Increase in abdominal pressure e.g. pregnancy, obesity, pelvic tumors, lifting, sitting, coughing, constipation, diarrhea, anal intercourse and aging are among the causes of developing hemorrhoids. Hemorrhoids can be exacerbated by excessive cleaning, rubbing, steroids, and hemorrhoid creams. Enlargement comes from the dragging of the hemorrhoids downward, weakened supporting tissue. There are many risk factors that promote hemorrhoids, from these factors; Past history of hemorrhoid symptoms or anal fissure, Age 30-65, heavy lifting, prolonged sitting, constipation/Diarrhea, pregnancy, failure to eat breakfast, spicy food, fats, alcohol, smoking, low water intake, obesity and spinal cord injuries.
Hemorrhoid Grades:
The severity is graded by the degree of prolapse
- Grade 1 hemorrhoid -no prolapse and cause painless bleeding.
- Grade 2 hemorrhoid – prolapse on defecation, go back spontaneously. Seen on straining.
- Grade 3 hemorrhoid – prolapse and have to be pushed back leading to bleeding and aching pain.
- Grade 4 hemorrhoid – Can’t be pushed back leading to mucous discharge, bleeding, pain and necrosis.
Typical Hemorrhoids Symptoms:
- Chronic intermittent bright red bleeding with bowel movements, on tissue, in commode, or streaked on stool surface.
- Feeling of fullness, swelling, extra tissue and incomplete BM.
- Irritation or itching from seepage of mucus, fecal soiling or dermatitis from hemorrhoid creams causes rash.
- Pain may occur with prolapse, associated external hemorrhoids or anal fissure.
- Bulge of tissue on anal skin
- Blood on toilet tissue.
- Thrombosis of external hemorrhoids leading to a hard painful lump.
- Skin tags left over after dilated external hemorrhoids, hemorrhoidectomy, or resolved thrombosis. Can trap stool and cause dermatitis and itching.
Diagnosis of Hemorrhoids:
1. History and physical exam including peril- anal inspection and digital rectal exam. Done in left lateral position. Side viewing anoscopy. Significant pain suggests thrombosis, fissure, spasm, proctitis or abscess.
2. Sigmoidoscopy to rule out tumors of lower colon
3. Manometry/endorectal ultrasound-incontinence study
4. Colonoscopy for persistent bleeding
Prevention of Hemorrhoids:
1- Eat foods high in fibers such as fresh fruits, leafy vegetables, and whole-grain breads and cereals. Eat additional fiber supplement available over the counter. Drink plenty of water and fluids, at least 6-8 glasses of water daily. Changing your eating and drinking lifestyle, avoid constipation and helps in passing the stool out easily.
2- Avoid sitting on the toilet for long periods of time. Use the toilet only whenever you feel the urge to have bowel movement. Prolonged sitting on the toilet as well as forcing out the stool causes the hemorrhoids to get worse.
3- Observe proper anal hygiene. Keep the area clean and dry at all times. Avoid scrubbing the area, for this further aggravates the hemorrhoids and causes irritation. When wiping, use a gentle and slow motion.
4- Using water to clean the area is the best, but if this is not possible, use a moist toilet paper or baby wipes.
5- Reduce your weight. Losing weight significantly decreases the pressure on the lower part of your body specifically the rectum area. Maintain a healthy weight for your height to get rid of hemorrhoids.
6- Avoid lifting heavy objects or other form of activity where you do excessive straining. Ask someone else to help you out.
7- Refrain from prolonged sitting for extended periods of time. This will limit the pressure being exerted on your bottom.
8- When your work requires you to be seated most of the time, take a break every now and then and walk around for few minutes
Medical treatment of hemorrhoids:
Apply ice pack to the affected area. It will give a quick relief from the pain and swelling by shrinking the veins. Be careful not to insert the ice directly into the rectum because it will burn your skin
Soak yourself in a warm tub or sitz bath several times a day for about 10 minutes. The warm water will ease the swelling and alleviate the pain associated with hemorrhoids. Make sure to use clean water free from any bath products.
Anorectal preparations may temporarily help relieve anal itching or irritation, but will not cure the problem of rectal bleeding and prolapse. Patients prefer creams over suppositories.
None surgical RBL of hemorrhoids:
1999- Dr. Patrick O’Regan develops a disposable ligation system featuring gentle suction instead of metal grasper.
2006- 2008 Centers for Colo Rectal Health opened in Chicago, Atlanta, Las Vegas, San Francisco, Los Angeles, Denver and New Orleans.
Ligator has now been proven safe and reliable in over 15,000 applications.
Banding normalized the size of hemorrhoidal cushions.
Inflammation reattaches tissue to surrounding muscles.
External disease improves but skin tags may be left behind.
Banding may be done via side viewing anoscope. Band is placed 1.5 to 2 cm above dentate line to decrease pain. After band is applied it is digitally checked for position and comfort.
Who can be banded?
- Patients may resume normal activities after the banding but should avoid strenuous activities until next day.
- There may be a feeling of heaviness or fullness for 1-2 days.
- Avoid constipation. Continue with fiber and fluids.
- Bleeding may occur which may be from associated fissure or other hemorrhoids. Lie down on side, drink fluids, apply ice to anal area, and if persists call physician.
- Call physician for urinary retention, fever, myalgia, flu like symptoms.
- The band will fall off and pass in 1-7 days.
Contraindication to banding:
Anticoagulants such as Coumadin, Plavix, or aspirin are a relative contraindication to hemorrhoid treatment and if possible it is best to stop them for 5 days before and after banding.
In portal hypertension the rectal varices are treated by treating the portal hypertension.
In pregnancy try to avoid rectal procedures to avoid the rare complication of pelvic sepsis or the liability of abortion. Anal fissures may be treated with Nitroglycerin.
Not capable of tolerating office procedure
Large external hemorrhoid disease?
Grade IV hemorrhoidal disease not responding to banding?
Other hemorrhoid treatment modalities:
Anti-inflammatory Cortisone preparation, reduce itching and swelling.
OTC products containing hydrocortisone are not FDA approved for internal anorectal use.
Prolonged use can weaken tissue, promote infection, and cause allergic reaction
Surgical treatment:
Prevention is the best line of treatment
Conservative treatment offer symptomatic relief but does not treat the cause
Rubber band ligation is a none surgical, safe, and painless, in – office treatment. This is the most recommended and effective first choice treatment
Surgical procedures are reserved for large external hemorrhoids and for internal hemorrhoids not responding to rubber band ligation.
Dr. Mando is the Medical Director of the Center for Colorectal Health in Louisiana.
