Hemorrhoids
Hemorrhoids are the swelling and inflammation of veins in the rectum and anus.
Prevalence
Hemorrhoids are very common. It is estimated that approximately half of all Americans have this condition by the age of 50. However, only a small number seek medical treatment. Annually, only about 500,000 people are medically treated for hemorrhoids, with 10 to 20% of them requiring surgeries.
Causes and risk factors
Some people are more prone to developing hemorrhoids due to inherent problems with their bodies' collagen and elastic fibers due to a genetic predisposition. This leads to weak rectal vein walls or week venous valves. These people may have other related defects such as 'flat feet', herniae. Others develop hemorrhoids due to problems in their intestinal tract.
The causes of hemorrhoids include genetic predisposition (weak rectal vein walls and/or valves, excessive time (over 1 minute daily) and straining during bowel movements, and chronic bowel straining or pressure due to poor posture or muscle tone. Constipation, bouts of diarrhea, poor bathroom habits (reading on the toilet or multiple cleaning attempts), pregnancy, excessive coughing, constant sitting and fiber-deprived Western diet can all foster the conditions that cause hemorrhoids.
Hemorrhoids is particularly common among pregnant women. The pressure of the fetus in the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.
Types of hemorrhoids
Hemorrhoids can present as internal or external hemorrhoids or both. External hemorrhoids are those that occur outside of the anal opening. Internal hemorrhoids are those that occur inside the rectum.
Clinical Picture
External hemorrhoids
External hemorrhoids are asymptomatic except when secondary thrombosis occurs. However, some patients with non-thrombosed hemorrhoids may complain of pruritus ani or itching, swelling, and burning sensation. In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.
If the vein ruptures and a blood clot develops, the hemorrhoids become a thrombosed hemorrhoid. Thrombosis may result from defecatory straining or extreme physical activity, or it may be a random event. Patients often report feeling the sensation of sitting on a tender marble. Physical examination identifies the external thrombosis as a purple mass at the anal verge.
If infected this can lead to inguinal lymph node enlargement. The inguinal lymph nodes are situated in the crease between the leg and pelvis (more on the outside of that crease, ie, laterally). They drain the penis, scrotum, vulva, vagina, perineum, gluteal region, lower abdominal wall, lower anal canal.
Internal hemorrhoids
As this area lack sensitive nerve endings, internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl.
Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids. Prolapsed hemorrhoid is an internal hemorrhoid that are so distended that it is pushed outside of the anus. If the anal sphincter muscle goes into spasm and trap the prolapsed hemorrhoid outside of the anal opening, the supply of blood is cut off, and the hemorrhoids become a strangulated hemorrhoid.
Differential Diagnosis
Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms. The differential diagnosis of anal mass includes many benign diseases. hemorrhoids, rectal prolapse, perianal haematomas, anal tags, polyps, warts or condylomas, anal abscesses can all present as an anal mass. Non-proctological lumps can also be present from time to time. These include sebaceous cysts and lipomas. On the other hand, a palpable mass and/or bleeding is the presenting symptom in 50% of patients that are later found to have anal cancer. Other potential causes include inflammatory bowel disease or bowel infection.
Diagnosis
A thorough evaluation and proper diagnosis are important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.
Examination of the anus and rectum to includes inspection to look for swollen blood vessels that indicate hemorrhoids and a digital rectal exam with a gloved, lubricated finger to feel for abnormalities. Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum.
To rule out other causes of gastrointestinal bleeding, examination of the rectum and lower colon (sigmoid) with sigmoidoscopy or the entire colon with colonoscopy may be necessary. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.
Prevention
Prevention of hemorrhoids includes drinking more fluids, eating more fiber, exercising, practicing better posture, and reducing bowel movement strain and time. Hemorrhoid sufferers should avoid using laxatives and should strictly limit time straining at stool to well under 1 minute (ideally 10 seconds) daily.
Treatments
For many people, hemorrhoids are temporary conditions that are healed either serendipitously or by the same measures recommended for prevention. In these cases, warm sitz bath, cold compress, or topical analgesic (such as Preparation H), is sufficient to provide temporary relief.
The first step is to eliminate the factors causing hemorrhoids. After eliminating the risk factors and possible causes the goal is to achieve symptomatic relief as well as shrinkage of the hemorrhoids. This can be accomplished by Sitz baths as well as pain meds.
Treatment of chronic or complicated hemorrhoids
Chronic hemorrhoids or those that flare up from time to time can be medically treated by:
* dilation: stretching of the anal sphincter muscle. Although no longer popular, this treatment can be successfully applied to select cases of strangulated hemorrhoids.
* rubber band ligation: elastic bands are applied onto an internal hemorrhoid to cut off its blood supply. Within several weeks, withered hemorrhoid is sloughed off during normal bowel movement.
* sclerotherapy (injection therapy): sclerosant or hardening agent is injected into hemorrhoids. This causes the vein walls to collapse and the hemorrhoids to shrivel up.
* cryosurgery: a frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues.
* laser, infared or BICAP coagulation: laser, infrared beam, or electricity is used to cauterize the affected tissues.
* hemorrhoidectomy: a true surgical procedure to excise and remove hemorrhoids.
For severe cases of hemorrhoids, such as prolapsed, thrombosed, or strangulated hemorrhoids, surgery may be the only treatment option. The pain in thrombosed external hemorrhoid, which is better known as a perianal haematoma, is usually severe and instantly relieved by incision and evacuation of the clot.
General measures to decrease flare ups and aggravation are increase dietary fiber found in fruits, vegetables, grains and cereals. A fiber supplement may also be used. Increase water intake. These measure may soften the bowel movements and prevent straining and trauma.
Natural astringents and soothing agents, such as witch hazel, cranesbill and aloe vera, may also be used topically. Lastly, fiber-rich bulking agents such as plantain and psyllium can be used to help create soft stool that is easy to pass to lessen the irritation of existing hemorrhoids or to achieve the daily limit of well under 1 minute (ideally 10 seconds) straining at stool.
