Colloquially referred to as piles, a hemorrhoid is a condition where the blood vessels in the anal canal and the lower rectum become swollen and inflamed. At times, they rupture and give rise to the presence of blood in the stool. This is the most common cause of rectal bleeding.

This is a varicose condition of the veins of the rectum and the anal canal.  Hemorrhoids are seen in about 4% of the population commonly between the ages of 45 to 65 years. About half of adults above the age of 50 have hemorrhoids

They are of two types:

  • Internal hemorrhoids, which develop inside the rectum
  • External hemorrhoids, which develop outside under the skin around the anus

External hemorrhoids

External hemorrhoids are those that occur outside the anus. The main symptom is more of pain and itching than bleeding. This occurs in the veins that drain the area supplied by the inferior rectal artery. Sometimes, the vein ruptures, and a blood clot forms. Such a hemorrhoid is called a thrombosed hemorrhoid.

Internal hemorrhoids

Internal hemorrhoids are those, which occur inside the rectum. These occur in the veins that drain the area of the superior rectal artery. They are painless as there are no pain sensors in this area. You may not know that you are having internal hemorrhoids until you see blood in the stools.

If untreated, the internal hemorrhoids may prolapse outside the rectum, in which case they are called prolapsed hemorrhoids.

Sometimes, the anal sphincter may go into spasm and the blood supply to the prolapsed hemorrhoids may get cut off.  This condition is called strangulated hemorrhoids.

Grading of internal hemorrhoids

Internal hemorrhoids are graded according to the degree of their prolapse below the pectinate line in the anal canal. According to the severity, they are graded in the following way.

Grade 1: This is the initial stage, where the swollen and inflamed blood vessels are inside the rectum.

Grade 2: In this stage, the hemorrhoids protrude outside the anus during the passing of the stools. They, however, retract on their own.

Grade 3: In the third stage, the hemorrhoids that have protruded outside the anus, do not go back on their own after passing the stools. They have to be pushed back manually.

Grade 4: In this stage, the hemorrhoids stay prolapsed and cannot be pushed back manually.

Causes of hemorrhoids

  • Low fiber diet
  • Chronic constipation, which forces one to strain during passing of stools
  • Hereditary or familial trend
  • Increase in abdominal pressure due to some pathology
  • Pregnancy: In Pregnancy, there may be pressure on the returning veins. This causes the rectal veins to become engorged. After the delivery, the piles may recede.
  • Advancing age
  • Obesity: The excess fat and the increased weight cause additional pressure on the anal muscles causing them to weaken and sag.
  • Prolonged sitting hours

Symptoms and signs

If you have external hemorrhoids, you may have

  • itching around the anus
  • rectal pain that occurs in external hemorrhoids or strangulated internal hemorrhoids
  • a lump may be felt around the anus.

If you have internal hemorrhoids, you may have

  • bleeding hemorrhoids. There is bleeding during the passing of the stools. The stools may be lined with blood or there may be passing of stream of frank red blood.
  • a feeling of incomplete evacuation
  • anemia caused by loss of blood
  • generalized weakness due to anemia

Diagnosis

Your signs and symptoms and the digital examination of the anus and rectum are enough for the proctologist to make the diagnosis of hemorrhoids. However, to know the degree of involvement, the doctor may perform an anoscopy, sigmoidoscopy, or proctoscopy.

The instrument used consists of a small fiber-optic camera fitted into a small tube. The camera helps to view the insides when the tube is inserted into the anus.

An anoscopy shows the inside part of your anus, a sigmoidoscopy examines the last foot and a half of your distal part of the colon, and a colonoscopy shows the inside of the entire colon.

Hemorrhoid treatments

Many a times, hemorrhoid symptoms usually go away on their own. Home remedies and simple lifestyle changes can often give relief from mild symptoms within 2 to 7 days.

Your attending doctor will know what to do best. Initially, he will advise a high fiber diet along with stool softeners. Mild anti-inflammatory pain killers along with sitz baths can be quite effective in relieving discomfort and pain.

At times, a procedure or surgery may be required to remove the hemorrhoids, especially in advanced and severe cases.

There are certain self-help measures you should adopt to help the hemorrhoids get better.

1. Dos and Don’ts

  • What to eat when you have hemorrhoids. Plan a high-fiber diet consisting of green vegetables, fruits, whole grains, and cereals. A high fiber diet prevents constipation and facilitates easy evacuation of the bowels.
  • Drink plenty of water – 4 to 5 liters per day if there are no contraindications.  The benefits are tremendous.
  • Sit on the toilet seat only till necessary.
  • If chronic constipation is present, take mild laxatives till necessary.
  • If anemia has developed due to blood loss, your doctor will prescribe iron medication.
  • Avoid alcohol.
  • Avoid fried and spicy foods.
  • Avoid tea, coffee, and carbonated drinks.
  • Avoid meats. You can have fish.

2. Conservative treatment

  • Hemorrhoids creams or suppositories that contain phenylephrine or steroids are available. Phenylephrine constricts the blood vessels. Steroids reduce that inflammation. The role of such topical creams is limited. Do not use an over-the-counter steroid cream for more than one week because it can cause thinning of your skin.
  • Sitting in a tub of warm water gives relief due to the relaxation of the anal sphincter.
  • Your doctor will prescribe antibiotics if there is an associated infection.
  • He may also prescribe oral anti-inflammatory pain relievers for pain that may be present.

3. Office procedures

  • Rubber band ligation: In this procedure, elastic bands are applied, at the right area above the inflamed hemorrhoids. This cuts off the blood supply to the hemorrhoids. The inflamed blood vessels wither and fall off.
  • Sclerotherapy: A doctor injects a sclerosing solution such as phenol into hemorrhoid, which causes the blood vessels to collapse and shrivel up.
  • Electrocoagulation or cauterization with electrocautery or radiation is also an effective method. The doctor uses a cautery (electric current) to burn and remove tissue and seal the end of the hemorrhoid, which then shrinks and closes. This procedure is ideal for prolapsed hemorrhoids.
  • External hemorrhoid thrombectomy. If a painful blood clot (thrombosis) has developed in an external hemorrhoid, your doctor will remove the hemorrhoid to relieve pain. This procedure is done under local anesthesia and is within 72 hours of the development of the clot.

4. Surgery

Surgery is resorted to when the conservative treatment does not give relief even after one month and in 3rd and 4th degree hemorrhoids.

Hemorrhoidectomy

Hemorroidectomy is a surgical operation, performed under spinal or local anesthesia, in which the doctor excises the affected hemorrhoids using a scalpel or a laser. This surgery is useful in internal and external hemorrhoids that are advanced and severe.

Hemorrhoidectomy  is indicated

  • in grade III and grade IV hemorrhoids associated with symptoms, or mixed internal and external hemorrhoids
  • strangulated internal hemorrhoids
  • some thrombosed external hemorrhoids

This is the most effective treatment though it is associated with a greater risk of complications. Recovery normally takes 2 to 3 weeks.

Stapled hemorrhoidectomy

Stapled hemorrhoidectomy is used for internal hemorrhoids and is generally less painful and the patient recovers faster. It  involves removal of soft tissue above the dentate line thereby stopping the blood supply to the hemorrhoids.

This type of surgery is indicated in patients with grade III and IV hemorrhoids. During a stapled hemorrhoidectomy, a circular stapling device excises the surrounding ring of excess hemorrhoid tissue, thereby putting the hemorrhoids back to their normal position within the anal canal.

Stapling also cuts off hemorrhoid blood supply. Stapled hemorrhoidectomy is associated with less postoperative pain and the recovery period is shorter compared with that of conventional surgery.

However, the rate of recurrence is higher. The risk of complications is similar to that following standard hemorrhoidectomy.

Outlook

If conservative treatments have not been successful, surgery offers an effective option with recovery within two to three weeks. However, it can take as long as 3 to 6 weeks to feel absolutely normal. You should avoid lifting heavy objects and straining.

Complications such as bleeding per rectum may occur, which the doctor will effectively treat.

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