Haemorrhoids
Introduction
Haemorrhoids are the most prevalent anorectal complaints among adults. Over 90% of patients undergoing sigmoidoscopy or colonoscopy have some form of haemorrhoids. Haemorrhoids are defined as internal and external according to whether they are located above or below the dentate line (the dermal-mucous line). Many non-surgical options are available for treatment. Nonoperative management is considered for patients with symptoms (anal bleeding or rectal prolapse) and grade 1, 2, and 3 internal haemorrhoids. Based on the results of a meta-analysis, researchers concluded that rubber band ligation should be recommended for grade 1 to 3 internal haemorrhoids and that patients treated by this method were less likely to require additional therapy than those treated with local injection therapy or infrared coagulation.
Anatomy and Classifiaction
Internal haemorrhoids are found in the right anterior, right posterior and left lateral positions within the anal canal. This was originally thought to be due to the terminal branching of the superior mesenteric artery, however recent studies have refuted this. The position of haemorrhoids within the anal canal however remains remarkably consistent.
Internal haemorrhoids are classified by history and not by physical examination.
Grading of haemorrhoids
- Grade I - bleeding without prolapse.
- Grade II - prolapse with spontaneous reduction
- Grade III - prolapse with manual reduction.
- Grade IV - incarcerated, irreducible prolapse.
This system has been in place for many years and correlates relatively well with treatment algorithms (ie Grade I and II hemorrhoids are often successfully treated by non operative means while Grade III and Grade IV hemorrhoids are more likely to require surgery).
Symptoms
In general, patients with varying rectal complaints seek medical attention complaining of "haemorrhoids".True haemorrhoidal symptoms, however, are relatively specific. There are two cardinal symptoms of internal haemorrhoids, bleeding and prolaps and mucosal irritation. Patients either present with bright red blood per rectum or a prolapsing anal mass. Bleeding associated with haemorrhoids generally occurs with, or following, bowel movements, is almost universally bright red, and very commonly drips into the toilet water. Blood may also be seen while wiping after defecation. Occasionally blood may stain the underclothes if haemorrhoidal prolapse is present. Bleeding associated with haemorrhoids is rarely mixed with the stool, dark, or melanotic in nature. Rarely individuals with large chronic haemorrhoids may present with anemia secondary to chronic blood loss.
Hemorrhoidal prolapse usually occurs in association with a bowel movement, particularly when straining is present. Hemorrhoids may also prolapse during walking or heavy lifting as a result of increased intra-abdominal pressure. The prolapse is associated with a full, uncomfortable feeling which resolves when the prolapse reduces. If incarcerated prolapse occurs then strangulation may develop. In this circumstance, patients present with extreme pain, bleeding and occasionally signs of systemic illness. These individuals may require urgent hemorrhoidectomy.
Office Treatment Of Internal Hemorrhoids
A haemorrhoid is an enlarged vein in the lining of the anal canal. All people have internal hemorrhoids. When these hemorrhoids become enlarged, they may cause painless rectal bleeding. Swelling of the haemorrhoid may cause it to prolapse (slide out) during a bowel movement.
Treatments
Your physician felt your hemorrhoids required one of the following treatments:
- Barron ligatures (rubber bands)--A rubber band is put around the hemorrhoid, causing it to wither and fall off over a seven- to ten-day period.
- Laser coagulation--A light source is used to cause a small burn on the surface of the hemorrhoid, causing it to stop bleeding and shrink down to normal size.
- Injection of hemorrhoids--A liquid is injected into the haemorrhoid, stopping the bleeding and preventing it from protruding.
- Haemorrhoidal artery ligation (HAL) --A suture is made over the artery which can be located with a doppler proctoscope, stopping the bleeding and preventing it from protruding.
These treatments are only used for internal haemorrhoids.
Treatment of external haemorrhoids are generally sowewhat more painful .
After Treatment
- Symptoms
You may feel mild to moderate pain, a dull ache, or essentially nothing for the first 36 to 48 hours. A sense of urgency to have a bowel movement is normal after these treatments. If discomfort is mild, take over-the-counter medications such as Tylenol® or Advil®. Do not take aspirin or products containing aspirin because they promote bleeding. If your pain is more severe, you will be given a prescription for pain medicine. Taking warm baths for 15 to 20 minutes will help relieve your discomfort.
Generally it takes two to four treatments three to six weeks apart to get rid of all the prolapsing internal hemorrhoids. Usually only one area, or occasionally two, is treated at a time. Remember that bleeding and prolapse will probably persist until all the hemorrhoids and prolapsing tissue have been treated. - Diet
After your treatment, it is important to keep your bowel movements soft and regular. Eat foods high in fiber and drink lots of water (6-8 glasses a day). Continue the fiber supplement recommended by your doctor. Caffeine contributes to constipation so limit your consumption of coffee, tea, colas, and chocolate. - Activity
You may continue your normal physical activities. You will be able to drive your car immediately, walk up stairs, and do normal exercise.
Causes For Concern
Call the doctor if you have any of the following problems:
- Pain that does not gradually lessen in three days
- Increasing pain several days after treatment
- Tender swelling in the anal area
- Fever or chills
- Difficulty urinating
- Severe constipation (no bowel movement for three days)
- Diarrhea (more than three watery stools within 24 hours)
- Increased bleeding (more than one cupful)
- Three to four large bloody bowel movements within three hours
- Drainage of pus from the rectum
If your own doctor is unavailable, the doctor on call is available 24 hours a day, every day of the year. After hours, call any of our offices and the answering service will locate one of our doctors on call. In an emergency try to contact us for advice before you go to the hospital. A telephone call may save you a lot of time, discomfort and expense.