Hemorrhoids

Hemorrhoids (AmE), haemorrhoids (BrE), are swelling and inflammation of veins in the rectum and anus. The anatomical term "hemorrhoids" technically refers to "cushions of tissue filled with blood vessels at the junction of the rectum and the anus".[1] However, the term is popularly used to refer to varicosities of the hemorrhoid tissue. Perianal hematoma are sometimes misdiagnosed and mislabeled as hemorrhoids, when in fact they have different causes and treatments.

Classification

Direct view of hemorrhoid seen on sigmoidoscopy

(I84.3-I84.5) External hemorrhoids are those that occur outside the anal verge (the distal end of the anal canal). Specifically they are varicosities of the veins draining the territory of the inferior rectal arteries, which are branches of the internal pudendal artery. They are sometimes painful, and by swelling and irritation. Itching, although often thought to be a symptom of external hemorrhoids, is more commonly due to skin irritation. o (I84.3) External hemorrhoids are prone to thrombosis: if the vein ruptures and/or a blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid.[3] (I84.0-I84.2) Internal hemorrhoids are those that occur inside the rectum. Specifically they are varicosities of veins draining the territory of branches of the superior rectal arteries. As this area lacks pain receptors, internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated. (I84.1) Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids: o Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside the anus. o If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid.

By degree of prolapse
The most common grading system was developed by Banov:[4][5]

Grading of Internal Hemorrhoids o Grade I: The hemorrhoids do not prolapse. o Grade II: The hemorrhoids prolapse upon defecation but spontaneously reduce. o Grade III: The hemorrhoids prolapse upon defecation, but must be manually reduced. o Grade IV: The hemorrhoids are prolapsed and cannot be manually reduced.

Symptoms
Many anorectal problems, including fissures, fistulae, abscesses, anal melanoma or irritation and itching, also called pruritus ani, have similar symptoms and are incorrectly referred to as hemorrhoids. Hemorrhoids are usually not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days. Although many people have hemorrhoids, and hemorroidial radiation, not all experience symptoms. The most common symptom of internal hemorrhoidial radiation is bright red blood covering the feces (hematochezia), on toilet paper, and/or in the toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding hemorrhoid. Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid. In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious circle of symptoms. Draining anal mucus, produced by the dentate line may also cause irritation.

Causes
Increased straining during bowel movements caused by constipation or diarrhea may lead to hemorrhoids.[6] It is thus a common condition due to constipation caused by water retention in women experiencing premenstrual syndrome or menstruation.[citation needed] Hypertension, particularly portal hypertension, can also cause hemorrhoids because of the connections between the portal vein and the vena cava which occur in the rectal wall known as portocaval anastomoses.[7]

Obesity can be a factor by increasing rectal vein pressure. Poor muscle tone or poor posture can result in too much pressure on the rectal veins.[citation needed] Pregnancy may lead to hypertension and increase strain during bowel movements, so hemorrhoids are often associated with pregnancy.[citation needed] Insufficient liquid can cause a hard stool, or even chronic constipation, which can lead to hemorrhoidal radiation.[citation needed]; Vitamin E deficiency is also a common cause.[citation needed] Eating spicy food does not cause hemorrhoids, though spicy foods may aggravate the condition.[citation needed]

Prevention
Prevention of hemorrhoids includes drinking more fluids, eating more dietary fiber (such as fruits, vegetables and cereals high in fiber), exercising, practicing better posture, and reducing bowel movement strain and time. Wearing tight clothing and underwear may also contribute to irritation and poor muscle tone in the region and promote hemorrhoid development.[citation needed] NDDIC states: The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass.[8] Women who notice they have painful stools around the time of menstruation would be well-advised to begin taking extra dietary fiber and fluids a couple days prior to that time. Fluids emitted by the intestinal tract may contain irritants that may increase the fissures associated with hemorrhoids. Washing the anus with cool water and soap may reduce the swelling and increase blood supply for quicker healing and may remove irritating fluid. Kegel exercises for the pelvic floor may also prove helpful. Many people do not get a sufficient supply of dietary fiber (20 to 25 grams daily), and small changes in a person's daily diet can help tremendously in both prevention and treatment of hemorrhoids.

Use of squat toilets

Based on their very low incidence in the underdeveloped world, where most people squat for bodily functions, hemorrhoids have been attributed to the use of the "sitting" toilet.[9] [10] Dr. Berko Sikirov published a study in 1987 testing this hypothesis by having hemorrhoid sufferers convert to squat toilets.[11] Eighteen of the 20 patients were completely relieved of their symptoms (pain and bleeding) with no recurrence, even 30

months after completion of the study. This chart summarizes the results. This study was undertaken in a very small number of people, when compared to the numbers involved in recognized high-quality trials. Therefore, the results, while highly suggestive, cannot be assumed to provide a firm conclusion. No follow-up studies have ever been published. The American Society of Colon & Rectal Surgeons is silent regarding the therapeutic value of squatting.

Examination
After visual examination of the anus and surrounding area for external or prolapsed hemorrhoids, a doctor may conduct a digital examination. In addition to probing for hemorrhoidal bulges, a doctor may also look for indications of rectal tumor or polyp, enlarged prostate and abscesses. Visual confirmation of hemorrhoids can be done by doing an anoscopy, using a medical device called an anoscope. This device is basically a hollow tube with a light attached at one end that allows the doctor to see the internal hemorrhoids, as well as polyps in the rectum. If warranted, more detailed examinations, such as sigmoidoscopy and colonoscopy can be performed. In sigmoidoscopy, the last 60 cm of the colon and rectum are examined whereas in colonoscopy the entire large bowel (colon) is examined. A pathologist will look for dilated vascular spaces which exhibit thrombosis and recanalization.

Treatments
Treatments for hemorrhoids vary in their cost, risk, and effectiveness. Different cultures and individuals approach treatment differently. Some of the treatments used are listed here in increasing order of intrusiveness and cost.

[edit] Home treatments

Temporary relief from symptoms can be provided by:

Hydrotherapy with a bathtub, bidet, or extend-able shower head. Especially in the case of an external hemorrhoids with a visible lump of small size, the condition can be improved with warm bath causing the vessels around the rectal region to be relaxed.[citation needed] Cold compress.[citation needed] Topical analgesic (pain reliever), such as cinchocaine or pramocaine. Systemic (pill-form) analgesic (pain reliever).

Topical corticosteroid such as hydrocortisone. (May weaken the skin and may contribute to further flare-ups.)[citation needed] Topical vasoconstrictor such as phenylephrine. Topical moisturizer. Topical astringent, such as witch hazel

Topical medicines may be delivered as an ointment or suppository. Some hemorrhoidspecific medications contain a mixture of multiple ingredients, such as Preparation H, Proctosedyl, and Faktu.

Surgical and non-medicinal treatments

Rubber band ligation, sometimes called Baron ligation. Elastic bands are applied onto an internal hemorrhoid to cut off its blood supply.[12] Within several days, the withered hemorrhoid is sloughed off during normal bowel movement. Hemorrhoidolysis, desiccation of the hemorrhoid by electrical current. Sclerotherapy, sclerosant or another 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. [13] Rarely used anymore because of side effects. Hemorrhoidectomy, a surgical excision of the hemorrhoid. Has possible correlation with incontinence issues later in life; in addition, many patients complain that pain during recovery is severe. For this reason it is often now recommended only for severe (grade IV) hemorrhoids. Transanal Hemorrhoidal Dearterialization (THD-HP) is a minimally invasive treatment for hemorrhoids and hemorrhoidal prolapse [14][15][16]. THD uses an ultrasound doppler to accurately locate the arterial blood inflow. With simple suture, these arteries are tied off and the prolapsed tissue is sutured back to anatomical position without excision of tissue. THD is performed above the nerve bundles, or dentate line. Because of this, there is very little pain. THD is typically performed in an out-patient setting and return to normal activities is within a few days. Stapled hemorrhoidectomy, a resection of a soft tissue proximal to the dentate line, which disrupts the blood flow to the hemorrhoids. It is generally less painful than complete removal of hemorrhoids and also allows for faster recovery times. It's meant for hemorrhoids that fall out or bleed and is not helpful for painful outside conditions. Doppler guided hemorrhoidal artery ligation, which cuts the artery that delivers blood to the hemorrhoid. It is the best treatment for bleeding piles, as the bleeding stops immediately.

Natural treatments

Eating fiber-rich diets, as well as drinking lots of water, help to create a softer stool that is easier to pass, to lessen the irritation of existing hemorrhoids.[18] Using the squatting position for bowel movements.[11]

Dietary supplements can help treat and prevent many complications of hemorrhoids, and natural botanicals such as Butchers Broom, Horse-chestnut, Hem-eez and bioflavonoids can be an effective addition to hemorrhoid treatment.
[19]

Butcher's Broom extract, or Ruscus aculeatus, contains ruscogenins that have anti-inflammatory and vasoconstrictor effects that help tighten and strengthen veins. Butcher's Broom has traditionally been used to treat venous problems including hemorrhoids and varicose veins.[20][21][22] Horse-chestnut extract, or Aesculus hippocastanum, contains a saponin known as aescin, that has anti-inflammatory, anti-edema, and venotonic actions. Aescin improves tone in vein walls, thereby strengthening the support structure of the vein. Double blind studies have shown that supplementation with horse-chestnut helps relieve the pain and swelling associated with chronic venous insufficiency.

Famous cases
George Brett of the Kansas City Royals famously had to leave game 2 of the 1980 World Series due to extreme pain from hemorrhoids, but returned in game 3 following a procedure to relieve the pain. In 1981 he missed 2 weeks of spring training having the hemorrhoids removed.

Diseases with similar symptoms

Symptoms associated with rectal cancer, anal fissure, anal abscess, anal fistula, perianal hematoma, and other diseases may be similar to those produced by hemorrhoids and may be reduced by the topical analgesic methods described above. For this reason, it is a good idea to consult with a physician when these symptoms are encountered, particularly for the first time, and periodically should the problem continue. In the US, colonoscopy is recommended as a general diagnostic for those over age 50 (40 with family history of bowel cancers)