Haemorrhoids or Piles

Internal Haemorrhoids are clumps of tissue within the anal canal that contain blood vessels, muscle, and elastic fibers. External Haemorrhoids are enlarged blood vessels surrounding the anus. Internal Haemorrhoids cause problems when they enlarge. The cause of the enlargement is not known.

Complications of internal Haemorrhoids include bleeding, anal itchiness, prolapse, incarceration and gangrene. Pain is not common.

The primary complication of external Haemorrhoids is pain due to blood clotting in the Haemorrhoidal blood vessels called perianal hematoma.

There are several theories a to why Haemorrhoids occur, including inadequate intake of fiber, prolonged sitting on the toilet, and chronic straining during a bowel movement. None of these theories has strong experimental support. Pregnancy is a clear cause of enlarged Haemorrhoids though the reason is unclear.

As the anal cushion of an internal Haemorrhoid enlarges, it bulges into the anal canal, loses its normal anchoring, and protrudes from the anus as a prolapsing internal Haemorrhoid. The Haemorrhoid is exposed to the trauma of passing hard stools, causing bleeding and sometimes pain.

The rectal lining that has been pulled down can secrete mucus. The presence of stools and constant moisture can lead to anal itchiness (pruritus ani), though itchiness is not a common symptom of Haemorrhoids.

The following are the different types of Haemorrhoids:

Haemorrhoids that bleed but do not prolapse.

Haemorrhoids that prolapse and retract on their own (with or without bleeding).

Haemorrhoids that prolapse but must be pushed back in by a finger.

Haemorrhoids that prolapse and cannot be pushed back in.

In general, the symptoms of external Haemorrhoids are different to the symptoms of internal Haemorrhoids. External Haemorrhoids can be felt as bulges at the anus, but they usually cause few of the symptoms that are typical of internal Haemorrhoids. External Haemorrhoids can cause problems, however, when blood clots inside them. This is referred to as a perianal hematoma. Thrombosis of an external Haemorrhoid causes an anal lump that is very painful (because the area is supplied by somatic nerves) and may require incision and drainage.

This small procedure can effect immediate symptom relief. The thrombosed Haemorrhoid may heal with scarring and leave a tagof skin protruding from the anus. Occasionally, the tag is large, which can make anal hygiene difficult or irritate the anus. In these cases, surgical excision might be necessary.

Perianal hematoma

Clot evacuated from perianal hematoma

By the history of symptoms, we can suspect that Haemorrhoids are present. The diagnosis of an internal Haemorrhoid is easy if the Haemorrhoid protrudes from the anus. Although a rectal examination with a gloved finger may uncover an internal Haemorrhoid high in the anal canal, a more thorough examination for internal Haemorrhoids is done visually using an proctoscope. As the proctoscope is withdrawn, the area of the internal Haemorrhoids is well seen. Straining by the patient may make the Haemorrhoids more prominent.

Rectal mucosal prolapse can also mimic internal Haemorrhoids. External Haemorrhoids appear as a lump and/or dark area surrounding the anus. If the lump is tender, it suggests that the Haemorrhoid is thrombosed.

Although we should try our best to identify the Haemorrhoids, it is perhaps more important to exclude other causes of Haemorrhoid-like symptoms that require different treatment. These other causes such as anal fissures, fistulae, perianal skin diseases, infections, and tumours, can be diagnosed on the basis of a careful examination of the anus and anal canal. Any lump needs to be carefully followed, however, and should not be assumed to be a Haemorrhoid, since there are rare cancers of the perianal area that may masquerade as external Haemorrhoids.

If there has been bleeding, the colon above the rectum needs to be examined to exclude causes of bleeding other than Haemorrhoids. Other serious causes include colorectal cancer, polyps, or inflammatory bowel disease. This examination can be done by either flexible sigmoidoscopy or colonoscopy.

It is believed generally that constipation and straining to have bowel movements promote Haemorrhoids and that hard stools can traumatise existing Haemorrhoids. It is recommended, therefore, that individuals with Haemorrhoids soften their stools by increasing their fluid and fiber intake in their diets. This is recommended for all patients who have Haemorrhoidal symptoms and can be the only treatment required for patients with first degree Haemorrhoids.

Vasoconstrictors applied to the perianal area may reduce swelling, pain and itching due to their mild anesthetic effect.

Daflon is a Micronised Purified Flavonoid Fraction (MPFF) that works better than fiber supplements. Its efficacy is deemed to be equivalent to a rubber-band ligation alongside the intake of fiber supplement in stopping anal bleeding due to Haemorrhoids.

Rubber band ligation

The principle of ligation with rubber bands is to encircle the base of the Haemorrhoidal 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. It can be used with first-, second-, and third-degree Haemorrhoids. Symptoms can recur several years later, but usually can be treated with further ligation.

The most common complication of ligation is pain, but it tends to be mild.

However, if the rubber band is applied too distally, the pain is immediate and severe. Bleeding one or two weeks after ligation occurs occasionally and can be severe. Rarely, cellulitis can begin in the tissues surrounding the anal canal. These rare infectious complications may occur in patients who have defective immune systems from chemotherapy, diabetes, and AIDS.

Surgical removal of Haemorrhoids (Haemorrhoidectomy) usually is reserved for patients with third or fourth-degree Haemorrhoids. During Haemorrhoidectomy, the internal and external Haemorrhoids are excised using diathermy. The wounds left by the removal are left open. This is performed as a daycase procedure. Post-surgical pain is the major problem with Haemorrhoidectomy. The addition of NSAIDs enhances the relief of pain. Delayed Haemorrhage 7 to 14 days after surgery occurs in 1-2% of patients. Wound infections are uncommon after Haemorrhoid surgery. Abscess occurs in less than 1% of cases.

However, patients commonly complain of discharge postoperatively and this is expected as the wounds are left open. If the wounds look clean, they do not necessarily need antibiotics. Patients should be advised to keep the area clean and dry, and avoid topical applications of ointments or powder.

Stapled Haemorrhoidectomy is a technique developed in the early 1990s but is a misnomer since the surgery does not remove the Haemorrhoids but, rather, the abnormally lax and expanded Haemorrhoidal supporting tissue. The arterial blood vessels that travel within the expanded Haemorrhoidal tissue are cut, thereby reducing the blood flow to the Haemorrhoidal vessels and reducing the size of the Haemorrhoids.During the healing of the cut tissues around the staples, scar tissue forms, and this scar tissue anchors the Haemorrhoidal cushions back to their normal position higher in the anal canal, thus effectively performing an anopexy.

External Haemorrhoids are not removed, however. Hence, this procedure is best suited for circumferential third or fourth Haemorrhoids, with minimal external components. It is associated with much less pain than a traditional Haemorrhoidectomy, and patients usually return earlier to work.

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Although rare, there are risks that accompany this procedure:

• If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall.
• The internal muscles of the sphincter may stretch, resulting in short-term or long-term dysfunction.
• As with other surgical treatments for Haemorrhoids, cases of pelvic sepsis have been reported following stapled Haemorrhoidectomy.
• Persistent pain and faecal urgency after stapled Haemorrhoidectomy.