What are hemorrhoids?

Hemorrhoids, often called piles, are swollen and inflamed veins in your anus and rectum. They may result from straining when having a bowel movement or the increased pressure on these veins during pregnancy. Veins in the anal area are normal but when they enlarge they can cause symptoms and are then called hemorrhoids.

Anatomy of hemorrhoids:

The arteries supplying blood to the anal canal descend into the canal from the rectum above and form a rich network of arteries that communicate with each other around the anal canal. Because of this rich network of arteries, hemorrhoidal blood vessels have a ready supply of arterial blood. This explains why bleeding from hemorrhoids is bright red (arterial blood) rather than dark red (venous blood), and why bleeding from hemorrhoids occasionally can be severe.

The anal veins drain blood away from the anal canal and the hemorrhoids, These veins drain in two directions. The first direction is upwards into the rectum, and the second is downwards beneath the skin surrounding the anus. The dentate line is a line within the anal canal that denotes the transition from anal skin to the lining of the rectum.

Formation of hemorrhoids:

If the hemorrhoid originates at the top (rectal side) of the anal canal, it is referred to as an internal hemorrhoid. If it originates at the lower end of the anal canal near the anus, it is referred to as an external hemorrhoid. Technically, the differentiation between internal and external hemorrhoids is made on the basis of whether the hemorrhoid originates above or below the dentate line (internal and external, respectively).

Hemorrhoidal cushions in the upper anal canal are made up of blood vessels and their supporting tissues. During the formation of enlarged internal hemorrhoids, the vessel of the anal cushions swell and the supporting tissues increase in size. The bulging mass of tissue and blood vessels protrudes into the anal canal where it can cause problems. Unlike with internal hemorrhoids, it is not clear how external hemorrhoids form.

Causes:

Hemorrhoids can develop from and increase in pressure in the veins in the lower rectum. Common sources of pressure include:

Symptoms from hemorrhoids:

There are two types of nerves in the anal canal, visceral nerves (above the dentate line) and somatic nerves (below the dentate line.) The somatic (skin) nerves are like the nerves of the skin and are capable of sensing pain. The visceral nerves are like the nerves of the intestines and do not sense pain, only pressure. Therefore, internal hemorrhoids, which are above the dentate line, usually are painless.

As the anal cushion of an internal hemorrhoid continues to enlarge, it bulges into the anal canal. It may even pull down a portion of the lining of the rectum above, lose its normal anchoring, and protrude from the anus. This condition is referred to as a prolapsing internal hemorrhoid. In the anal canal, the hemorrhoid is exposed to the trauma of passing stool, particularly hard stools associated with constipation. The trauma can cause bleeding and sometimes pain when stools pass. The rectal lining that has been pulled down secretes mucus and moistens the anus and surrounding skin. Stool also can leak onto the anal skin. The presence of stool and constant moisture can lead to anal itchiness (pruritus ani), though itchiness is not a common symptom of hemorrhoids. The prolapsing hemorrhoid usually returns into the anal canal or rectum on its own or can be pushed back inside with a finger, but it prolapses again with the next bowel movement. Less commonly, the hemorrhoid protrudes from the anus and cannot be pushed back inside, a condition referred to as incarceration of the hemorrhoid. Incarcerated hemorrhoids can have their supply of blood shut off by the squeezing pressure of the anal sphincter, and the blood vessels and cushions can die, a condition referred to as gangrene. Gangrene requires medical treatment.

For convenience in describing the severity of internal hemorrhoids, many physicians use a grading system:

First-degree hemorrhoids: Hemorrhoids that bleed but do not prolapse.

Second-degree hemorrhoids: Hemorrhoids that prolapse and retract on their own.

Third-degree hemorrhoids: Hemorrhoids that prolapse but must be pushed back by the finger.

Fourth-degree hemorrhoids: Hemorrhoids that prolapse and cannot be pushed back in. Fourth-degree hemorrhoids also include hemorrhoids that  thrombosed (contain blood clots) or that pull much of the lining of the through the anus.

In general, the symptoms of external hemorrhoids are different than the symptoms of internal hemorrhoids. External hemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal hemorrhoids. This is perhaps, because they are low in the anal canal and have little effect on the function of the anus, particularly the anal sphincter. Enlargement can cause pain and discomfort. Sever pain can occur when a blood clots develops inside the hemorrhoid, this is referred to as thrombosis.Thrombosis of an external hemorrhoid causes and anal lump that is very painful (because the area is supplied by somatic nerves) and often requires medical attention. The thrombosed hemorrhoid may heal with scarring and leave a tag of skin protruding from the anus. Occasionally, the tag is large, which can make anal hygiene (cleaning) difficult or irritate the anus.

Diagnosis:

Most individuals who have hemorrhoids discover them in one of several ways. They either feel the lump of an external hemorrhoid when they wipe themselves after a bowel movement, note drops of blood in the toilet bowl or on the toilet paper, or feel a prolapsing hemorrhoid (protruding from the anus) after bowel movements. Severe anal pain may occur when an external hemorrhoid thromboses or a prolapsing internal hemorrhoid becomes gangrenous. Symptoms of anal discomfort and itching may occur, but anal conditions other than hemorrhoids are more likely to cause these symptoms than hemorrhoids.

External hemorrhoids appear as a bump and/or dark area surrounding the anus. If the lump is tender, it suggests that the hemorrhoid is thrombosed. Any lump needs to be carefully followed, however, and should not be assumed to be a hemorrhoid since there are rare cancers of the perianal area that may masquerade as external hemorrhoids.

The diagnosis of an internal hemorrhoid is easy if the hemorrhoid protrudes from the anus. Although a rectal examination with a gloved finger may uncover an internal hemorrhoid high in the anal canal, the rectal examination is more helpful in excluding rare cancers that begin in the anal canal and adjacent rectum. A more thorough examination for internal hemorrhoids is done visually using an anoscope. An anoscope is a three-inch long, tapering, tube approximately one inch in diameter at its viewing end. The anoscope is inserted into the anus and the area of the internal hemorrhoids is well seen.

Whether or not hemorrhoids are found, if there has been bleeding, the colon above the rectum needs to be examined to exclude important causes of bleeding other than hemorrhoids. Other causes include colon cancer or colitis. This examination can be accomplished by either flexible sigmoidoscopy or colonoscopy.

Medical Treatment

The treatment for hemorrhoids is different depending on the severity of the problem. Most of the time, the treatment is conservative and performed at home.

Warm sitz bath:

A sitz bath is recommended 3 times a day and after each bowel movement for at least 15 minutes. For a sitz bath, sit in a few inches of  warm water in a tub. This is the best way to lessen the swelling and the pain. This treatment is usually more effective then medications.

Dietary changes:

Drink more liquids and eat more leafy green vegetables, which will makestools bulkier and softer to relieve constipation. Some people with constipation or hard stools may benefit from increasing the amount of fiber in their diet. Fiber can be found in band cereals and whole wheat breads. Also over the counter fiber can be added.

Over-the -counter medications:

Many over-the-counter products are sold for the treatment of hemorrhoids. These often contain the same drugs that are used for treating anal symptoms such as itching or discomfort. There are few studies showing that they do anything for hemorrhoids. Products used for the treatment of hemorrhoids may have local anesthetics to temporarily relieve pain, burning, and itching by numbing the nerve endings. Others contain vasoconstrictors to reduce the size of the vessels and thus decrease swelling. Some contain protectants that form a physical barrier on the skin that prevents contact of the irritated skin with aggravating liquid or stool from the rectum. All these are of short term help and do not resolve the hemorrhoid problem itself. Still the best medical treatment for hemorrhoid discomfort is Sitz bath and increasing the fiber in your did to resolve constipation.

Nonoperative treatment for Internal hemorrhoids

There are several nonoperative treatments for internal hemorrhoids. All of them have the same effect. These procedures cause inflammation in the hemorrhoidal cushions, which then produces scarring. The scarring causes the cushions to shrink and attach to the underlying muscle of the anal canal. This prevents the cushions from being pulled down into the anal canal. These treatments do not require anesthesia since the area contains only visceral nerves and thus do not cause pain.

Sclerothreapy:

A liquid (phenol or quinine urea) is injected into the base of the hemorrhoid. Inflammation sets in, and ultimately scarring takes place.

Heat coagulation:

There are several treatments that use heat to kill hemorrhoid tissue and promote inflammation and scarring, including bipolar diathermy, direct-current electrotherapy, and infrared photocoagulation.

Cryotherapy:

Cryotherapy uses cold temperatures to obliterate the veins and cause inflammation and scarring.

Rubber band ligation:

The principle of ligation with rubber bands is to encircle the base of the hemorrhoidal anal cushion with a tight rubber band. The tissue cut off by the rubber band dies and is replaced by an ulcer that heals with scarring. This is usually very effective and the treatment most often used.

Surgical Treatment of Hemorrhoids

Thrombosised external hemorrhoids:

This problem can usually be treated in the office under local anesthetic. After injecting the local anesthetic the hemorrhoid is incised and the clotted blood in the hemorrhoid is removed along with the hemorrhoid.

Surgical Excision:

Surgical removal of hemorrhoids (hemorrhoidectomy) usually is reserved for those patients that can not be treated by medical means or the banding technique.  During hemorrhoidectomy, the internal hemorrhoids and external hemorrhoids are cut out and the over lying mucosa sutured closed. The surgery is successful but it does cause considerable pain and thus is used only as last resort. General or spinal anesthetic is usually necessary but it can often be done as an outpatient procedure. Pain medication along with Sitz bath are prescribed on the postoperative period.

Hemorrhoid Prevention

Eat high fiber foods. Eat more fruits, vegetables and grains. Doing so softens the stool and increases its bulk, which will help lessen the straining that can cause hemorrhoids.

Drink plenty of liquids. The exact amount of water and other fluids you should drink each day  varies and depends on your age, health, activity level and other  factors.

Consider fiber supplements. Over-the -counter products such as Metamucil and

Citrucel can help keep stools soft and regular. If you use fiber supplements, be sure to drink eight to ten glasses of water or other fluids every day. Otherwise, fiber supplements can cause constipation or make constipation worse.

Exercise. Stay active to reduce pressure on veins, which can occur with long periods of standing or sitting, and to help prevent constipation.

Avoid long periods of standing or sitting. If you must sit for long periods, don't use an inflatable doughnut cushion to  pad your chair. It can increase the pressure on the veins in the lower rectum

Don't strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum

Go as soon as you feel the urge. If you wait to pass a bowl movement ant the urge goes away, tour stool could become dry and be harder to pass.