|
|
Hemorrhoids
What are hemorrhoids?
Hemorrhoids are the swelling of veins in the anal area that often accompany poor function of the bowel. Hemorrhoids are either external (under the skin around the anus) or internal (inside the anus).
Hemorrhoids are very common and approximately half of the population experiences hemorrhoids by the age of 50. Hemorrhoids affect both men and women equally. Even though they may be annoying or painful, they are not life threatening.
What are the risk factors?
Hemorrhoids are common in people who are obese, those with chronic constipation or people who do not receive adequate levels of fiber in their diet. They are also very common during pregnancy.
What causes them?
Hemorrhoids can be caused by increased pressure or straining during bowel movements or via other factors, such as pregnancy, aging and chronic constipation or diarrhea. There are several things you can do to reduce your risk of developing hemorrhoids.
Maintain good hygiene – Be sure to wash around the anal area with soap and water when bathing.
Clean yourself correctly – Use a soft toilet tissue and wipe gently but thoroughly after a bowel movement.
Go to the bathroom regularly – Don&rsduo;t ignore the urge to go to the bathroom and don&rsduo;t strain when defecating.
Eat well – Consumption of a high fat, low fiber diet without adequate fluid intake may contribute to hemorrhoids by causing constipation, so pay attention to your diet and include lots of foods that are high in fiber, such as whole grains, brans, breads and cereals. Potatoes and leafy vegetables provide bulk and fruits provide a natural laxative. Never skip meals and eat regularly and slowly.
Avoid laxatives – Prolonged use of harsh laxatives can actually be harmful.
Take a stool softener – Stool softeners are useful because they don&rsduo;t irritate hemorrhoids or fissures.
Call the doctor – Call your doctor if you experience any of the following: changes in bowel movement, a loss of weight or appetite, diarrhea or cramping, nausea, vomiting or persistent pain.
What are the symptoms?
Hemorrhoids often cause pain and bright red rectal bleeding. Blood will either appear on the stool or on the toilet tissue after wiping. Since rectal bleeding can also be caused by other more serious diseases or conditions, it is important to see a doctor for examination.
Symptoms of anorectal disease – bleeding, itching, burning, tissue prolapse, pain – are frequently attributed to “hemorrhoids” by both patients and physicians without an adequate search for other causes. Unfortunately, these symptoms are as likely to be caused by anal fissure, fistula, abscess, rectal cancer, anal cancer, warts, pruritus ani (“itchy bottom”), proctalgia fugax (pelvic floor spasm) and rectal prolapse, as they are to be a consequence of hemorrhoidal disease. The multi-billion dollar industry of over-the-counter hemorrhoidal remedies serves to reinforce this misconception in the lay public, and the natural aversion to performing anorectal examination contributes to the ease of making the diagnosis of “hemorrhoids” by physicians without an adequate investigation for other causes of the patient&rsduo;s symptoms. For patients misdiagnosed with “hemorrhoids” that have another benign cause of their anorectal symptoms, this misguided practice results in a delay in diagnosis and appropriate treatment. However, for patients with cancer of the anus or rectum, such a delay can be fatal.
Symptomatic hemorrhoids, however, are a significant cause of morbidity in our society. Hemorrhoids are vascular cushions located in the distal rectum and anal canal, whose exact function is unknown, although they may play a role in discrimination of rectal contents and fecal continence. Despite popular misconceptions, hemorrhoids are normal anatomic structures. They consist of a network of small arteries and veins surrounded by a supporting matrix of collagen and smooth muscle. This matrix helps to anchor the hemorrhoid to the underlying muscle of the rectal wall. Internal hemorrhoids arise from inside the rectum and are usually painless unless they prolapse outside the anus. External hemorrhoids consist of small veins at the anal opening. They can produce acute pain and swelling when the blood inside clots.
How are hemorrhoids diagnosed?
Any time rectal bleeding or blood in the stool is present, it is important to contact a doctor and schedule a thorough evaluation. It is necessary to perform a detailed anorectal examination, which should include proctoscopy and anoscopy. These examinations allow doctors to look for swollen blood vessels that may indicate the presence of hemorrhoids.
Examination of the colon with flexible sigmoidoscopy, colonoscopy or air-contrast barium enema should be performed in patients whose symptoms are atypical, or whose age, medical history or family history of colorectal neoplasia places them at risk of developing colorectal carcinoma.
What treatments are available?
Treatment of Internal Hemorrhoids
The selection of the various treatment options for symptomatic hemorrhoids depends on the severity of symptoms and the degree of prolapse. Regardless, increasing fiber consumption and fluid consumption is the mainstay of treatment. This regimen will bulk the stool and reduce straining at defecation. Caffeine and alcohol should also be avoided, as they are diuretics. Patients should be counseled to avoid prolonged periods of straining, and reading material and other distracters should be removed from the bathroom. Topical steroids, such as hydrocortisone suppositories, may help reduce inflammation and swelling. The vast majority of other over-the-counter remedies have no therapeutic value.
Symptomatic first-, second-, and third-degree hemorrhoids may be treated in the office by elastic ligation (banding), sclerotherapy and infrared photocoagulation. Each of these procedures produces inflammation and subsequent scarring that fixes the hemorrhoid to the rectal wall and thus prevents it from swelling and protruding outside the anus. Elastic ligation (rubber banding) has been shown to be the most effective and least expensive of these methods. Usually elastic ligation can be performed quickly and virtually painlessly in the office without an anesthetic. Pain after the procedure is usually mild and complications are rare. Delayed bleeding and clotting of the external hemorrhoids occur in less than 3 percent of patients after elastic ligation. Although the serious complication of perineal sepsis is extremely rare, any patient with severe anal pain, fever, or urinary retention after elastic ligation warrants immediate evaluation.
Other outpatient treatment methods, such as bipolar diathermy, direct-current electrocoagulation and cryotherapy, have been advocated by some practitioners, but are not recommended because of lack of proven results and/or higher complication rate. Anal dilatation has also been used as a treatment for symptomatic hemorrhoids, primarily based on the finding that some patients with hemorrhoidal disease have elevated anal sphincter resting pressures as measured by anal manometry. Although dilatation may improve hemorrhoidal symptoms in some patients, most colon and rectal surgeons have avoided this technique because of the risk of sphincter disruption and anal incontinence.
Excisional hemorrhoidectomy is reserved for patients with a large external component of their disease, for patients who fail elastic ligation or for patients with hemorrhoids that prolapse outside of the anus and cannot be reduced back inside. The procedure is usually performed on an outpatient or short-stay basis under local or regional anesthesia. Urinary retention occurs in up to 10 percent of patients, and most patients report discomfort for several weeks following the procedure. Hemorrhage and anal stenosis occur in 1-2 percent of patients. Excisional hemorrhoidectomy is an effective treatment for symptomatic hemorrhoids, with excellent long-term patient satisfaction. However, patients who return to straining at stool because of their dietary or bathroom habits may eventually have recurrent symptoms.
Laser hemorrhoidectomy has been advertised by some practitioners as a less traumatic and less painful method of performing excisional hemorrhoidectomy. However, research has shown no benefit to laser hemorrhoidectomy versus standard hemorrhoidectomy, and the extra cost of the procedure is not warranted. A novel method of hemorrhoidectomy – circular stapled hemorrhoidectomy or hemorrhoidopexy – has undergone clinical testing and been shown to be as effective as standard excisional hemorrhoidectomy for patients with primarily internal hemorrhoids, with reduced postoperative pain.
Hemorrhoidal disease in patients with inflammatory bowel disease should be approached with caution. Although hemorrhoids are usually considered to be unrelated to inflammatory bowel disease, patients with Crohn&rsduo;s disease undergoing hemorrhoidectomy may develop fistulas and nonhealing wounds. Some patients have even required proctectomy for complications related to hemorrhoidectomy performed in the setting of active proctitis.
Treatment of External Hemorrhoids
The clotting of an external hemorrhoid is one of the most common causes of acute anal discomfort. The patient will often report the acute onset of pain and a palpable lump at the anal verge following straining at defecation or vigorous physical activity. Patients who present with severe discomfort are best managed by excision of the clot and overlying skin under local anesthesia. Simple incision and evacuation of the clot is associated with early re-clotting and is not recommended. Most patients, however, are seen several days after the onset of symptoms, when their severe pain is subsiding. They are best managed with sitz baths, analgesics, fiber supplements and reassurance. The thrombosis will resolve within 4 to 6 weeks. Some patients will have a residual skin tag at the site of the thrombosed external hemorrhoid, but most are asymptomatic.
|
|
|