Hemorrhoids

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[edit] Hemorrhoids

Introduction:

Hemorrhoids (or "piles as some people call them colloquially) are enlarged vascular channels above or below the anal ring. They occur in adults in about 10% to 25% of the population and are found more often in people who suffer from constipation. It tends to run in families who have more problems with their veins as they also often have varicose veins in their lower legs. Women can develop hemorrhoids during a pregnancy following difficult labor and from then on these hemorrhoids may get bigger with every subsequent child. What is not widely known is that small hemorrhoids that are without any symptoms are a normal part of the anatomy and help the mechanism of achieving a tight seal at the anal ring that prevents soiling. When hemorrhoidal disease develops, it becomes a pathological condition. This condition is associated with symptoms such as itching, prolapse and bleeding (Ref.1). Hemorrhoidal disease affects about 15% to 25% of adults and the peak occurrence of this condition is between 45 and 65 years. There are two types of hemorrhoids, internal hemorrhoids and external hemorrhoids. The line of demarcation between the two is the "dentate line" which is shown here: Internal hemorrhoids, which are the ones above the dentate line, are graded by degree of severity into 4 different grades.

Severity of internal hemorrhoids
Grade of hemorroid:	Comments regarding implications:
First-degree hemorrhoids:	bleeding with defecation
Second-degree hemorrhoids:	Prolapsing with defecation, but returning spontaneously to ortiginal position
Third-degree hemorrhoids:	Prolapsing through anal canal at any time and with defecation. Has to be replaced manually
Forth-degree hemorrhoids:	In this case the hemorrrhoids are prolapsed permanently

This distinction is important as the lining of the mucous membrane above the dentate line is different when compared to below that line. Above the dentate line from where internal hemorrhoids develop the lining consists of columnar epithelium, which is more sensitive to touch. Below the dentate line where external hemorrhoids can develop, the lining consists of squamous epithelium, which is thicker and not so sensitive. Above the dentate line rectal cancer can develop and when it does, it would likely be an adenocarcinoma, which has a glandular appearance under the microscope. The columnar epithelium is more friable and bleeds easier. From a clinical point of view it is the internal hemorrhoids (with the 4 grades mentioned above) that are important. The external hemorrhoids are clinically not as important except when they thrombose and the patient experiences excruciating pain. Usually thrombosed external hemorrhoids heal up nicely within 2 t o3 weeks and end up as harmless skin tags.

Symptoms:

Internal hemorrhoids become symptomatic when a person is chronically constipated with infrequent, but hard stools that are difficult to evacuate. With the straining there is an increase of pressure inside the pelvic cavity, which results in significant congestion of the pelvic veins. These are connected with the perianal veins and the submucosal veins.

There can be painless bleeding. Sometimes blood from an internal hemorrhoid accumulates between two bowel movements and is evacuated with the next bowel movement. It may look blackish (melena) when it has stayed some time in the rectum. When internal hemorrhoids prolapse, there can be mucous production and blood and mucous may mix and stain the underwear. Mucous on the anal skin creates an annoying itch.

Diagnosis:

This image shows how the anoscope can be used to diagnose internal hemorrhoids (in this case grade 2 internal hemorrhoids). Flexible sigmoidoscopy is also useful to visualize the entire rectum to visualize the extent of the internal hemorrhoids: Second-degree hemorrhoids that return spontaneously to the original position can be quite tricky to be diagnosed. There will be flares of symptoms when the hemorrhoids prolapse, but this is followed by a quiescent period without symptoms. However, in both instances flexible sigmoidoscopy will visualize the internal hemorrhoids.

Treatment:

Grade 1 and early grade 2 internal hemorrhoids usually respond well to dietary changes. A high fiber diet with 30 grams of fiber daily is gradually phased in along with 6 to 8 glasses of water to produce more bulky, soft stools. A bowl of bran cereal has only about 7 grams of fiber. Psyllium (Metamucil) and hydrophilic colloid are other fibers that can be added. These fiber products are harmless as they work quite differently from laxatives. They bind water and keep moisture in the stool adding bulk and softness. Patients are told to avoid straining. This will allow the vein cushions to retract and become less filled with blood, which gradually normalizes the blood flow. Smaller hemorrhoids can disappear while early grade 2 hemorrhoids can reduce into a grade 1 hemorrhoid. With grade 2 and 3 hemorrhoids sclerosing agents can be injected. Rubber band ligation is also an alternative that can be done at the surgeon’s office. Other treatments are infrared photocoagulation, electrocoagulation or the application of a heater probe. With grade 4 hemorrhoids the surgery of choice is a hemorrhoidectomy by a general surgeon or by a proctologist. A 17 year follow-up study found a 26% recurrence rate and only 11% needed a second procedure done (Ref.1). A newer procedure is PPH, which stands for procedure for prolapse of hemorrhoids. This procedure is used for third-degree and forth-degree internal hemorrhoids. There is less pain with this procedure, but there are slightly higher complication rates than with conventional (more painful) surgical hemorrhoidectomy.

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