How can hemorrhoids occur?
Veins around the anus or in the lower rectum that are swollen and irritated are known as hemorrhoids. The large intestine ends in the rectum, which connects to the anus. The digestive tract's anus is the opening where bowel contents exit the body.
Hemorrhoids' several types
Hemorrhoids on the outside
The anal orifice, just below the surface of the skin, is where external hemorrhoids are found. Unless they thrombose, these tissues rarely cause difficulties (form a blood clot). A lump that is firm and blue may develop when this happens. Moreover, a thrombosed hemorrhoid produces abrupt, excruciating discomfort. The clot may naturally dissolve over time. Sometimes the tissue is so stretched by the clot that it forms a "skin tag."
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.
What causes and make risk to 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.
A visual exam is used to view the outer anal skin.
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.
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. It is usually 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 Sclerothermy
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.
How to Avoid Hemorrhoids
The secret to prevention is a healthy diet and practices that result in softer stools and less straining.
Increase fiber intake (fruits, vegetables, legumes, and whole grains).
Good sources of dietary fiber include:
Whole grain
Dark rice
Oatmeal
Pears
Carrots
Buckwheat
Bran
Dietary fiber aids in the development of intestinal bulk, which softens the stool and makes it simpler to pass.
Drink a lot of water (8 to 10 glasses of water daily).
Push bowel movements slowly and without exertion, but try to avoid spending too much time on the toilet.
After a bowel movement, refrain from wiping vigorously (to decrease irritation).
If overweight, lose weight.
Regular exercise.
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