Hemorrhoid

Hemorrhoid
Specialty	General surgery

Hemorrhoids (AmE), haemorroids (BrE), emerods, or piles) are varicosities or swelling and inflammation of veins in the rectum and anus.

Types and symptoms of hemorrhoids

File:Hemorrhoids2.jpg

Direct view of hemorrhoid seen on sigmoidoscopy

• (I84.3) If the vein ruptures and a blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid.
  • (I84.3-I84.5) External hemorrhoids are those that occur outside of the anal verge (the distal end of the anal canal). They are sometimes painful, and can be accompanied by swelling and irritation. Itching, although often thought to be a symptom from external hemorrhoids, is more commonly due to skin irritation.
• (I84.0-I84.2) Internal hemorrhoids are those that occur inside the rectum. 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:
  • Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside of the anus.
  • If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside of the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid.

Prevalence

Template:Globalize/USA Hemorrhoids are very common. It is estimated that approximately one half of all Americans have had this condition by the age of 50, and that 50% to 85% of the worlds population will be affected by hemorrhoids at some time in their life. However, only a small number seek medical treatment. Annually, only about 500,000 people in the U.S. are medically treated for hemorrhoids, with 10 to 20% of them requiring surgeries.

Causes

The causes of hemorrhoids include genetic predisposition (weak rectal vein walls and/or valves), straining during bowel movements, and too much pressure on the rectal veins due to poor muscle tone or poor posture. Hemorrhoids may also result from portal hypertension because of the portacaval anastomoses. Hemorroids are also linked to sitting for prolonged periods of time.

Additional factors that can influence the course of hemorrhoids (mostly by increasing rectal vein pressure), especially for those with a genetic predisposition, are obese and live a sedentary lifestyle.

Constipation, chronic diarrhea, poor bathroom habits, pregnancy, postponing bowel movements, and fiber-deprived diet may be associated with bowel movement and straining, but not all of these have been conclusively proved to cause hemorrhoids.

Squatting

Using a squat toilet has been hypothesised to reduce straining and therefore reduce the occurrence of hemorrhoids . However, the medical research into this subject is scarce, and there has been no definite proof for this hypothesis. Hemorrhoids are very rare in nations where people squat to defecate , but this epidemiological argument doesn't necessarily prove a causal relationship.

Food

Insufficient hydration (caused by not drinking enough water, or by drinking too much diuretic liquid such as coffee or cola) can cause a hard stool, which can lead to hemorrhoidal irritation. An excess of lactic acid in the stool, a product of excessive consumption of milk products such as cheese, can cause irritation and a reduction of consumption can bring relief. Vitamin E deficiency is also a common cause. Excessive alcohol consumption can cause diarrhea which in turn can cause hemorrhoidal irritation.

Prevention

Prevention of hemorrhoids includes drinking more fluids, eating more dietary fiber, exercising, practicing better posture, and reducing bowel movement strain and time. Hemorrhoid sufferers should avoid using laxatives and should strictly limit time straining during bowel movement. Wearing tight clothing and underwear will also contribute to irritation and poor muscle tone in the region and promote hemorrhoid development. Some sufferers report a more comfortable experience without underwear or wearing only very lightweight panties, etc.

Straining can be lessened by defecating in a standing position, knees slightly bent. This position seems to use the muscles of the abdomen to expel feces preventing a strain on the anus. 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.

Examination

Endoscopic image of internal hemorrhoids seen on retroflexion of the flexible sigmoidoscope at the ano-rectal junction

After visual examination of the anus and surrounding area for external or prolapsed hemorrhoids, a doctor would conduct a digital examination. In addition to probing for hemorrhoidal bulges, a doctor would 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 60cm of the colon and rectum are examined whereas in colonoscopy the entire bowel 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.

Temporary relief

For many people, hemorrhoids are mild and temporary conditions that heal spontaneously or by the same measures recommended for prevention. There is no medicine that will cure hemorrhoids, but local treatments such as warm sitz baths, using a bidet, extendable showerhead, cold compress, or topical analgesic (such as Nupercainal), can provide temporary relief. Consistent use of medicated creams (such as Anusol and Preparation H) during the early stages of a hemorrhoid flare-up will also provide relief and may stave off further development and irritation. However, creams containing steroid preparations weaken the skin and may contribute to further flare-ups. Keep the area clean and dry, with some lubrication provided by hemorrhoidal creams or a lubricant, such as Surgi-lube or petroleum jelly. Suppositories can also relieve the symptoms.

Natural treatments

Some people successfully apply natural procedures for treatment or reversal of chronic conditions. These procedures largely echo the prevention measures. However, you should always inform your doctor of any self-care measures you have taken, including herbal or "natural" remedies, to avoid possible drug interactions. Although unorthodox, olive oil has been known to bring relief.

They include:

• Reducing regional pressure in such ways as improving posture and muscle tone
• Taking herbs and dietary supplements that strengthen vein walls, such as butcher's broom, horse chestnut, bromelain, and Japanese pagoda tree extracts. Drinking 99% pure aloe juice can also relieve itching and swelling.
• Topical application of natural astringents and soothing agents, such as Witch hazel (astringent), cranesbill and aloe vera
• Eating fiber-rich bulking agents such as plantain and Psyllium seed husks to help create soft stool that is easy to pass to lessen the irritation of existing hemorrhoids.
• Using the squatting position for bowel movements.

Oral dietary supplementation can help to treat and prevent many complications of hemorrhoids, and natural botanicals such as Butchers Broom, Horse Chestnut, and bioflavonoids can be an effective addition to hemorrhoid treatment.

Butcher's Broom: Butcher’s broom extract, or Ruscus aculeatus, contains ruscogenins that have anti-inflammatory and vasoconstrictor effects. Supplementation with Butcher’s Broom helps tighten and strengthen veins. Butcher’s broom has traditionally been used to treat venous problems including hemorrhoids and varicose veins.

Horse Chestnut: 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.

Bilberry Bioflavonoid: Bilberry extract, or Vaccinium myrtillus, is an anthocyanoside bioflavonoid. Supplementation with this potent flavonoid protects and maintains venous strength and function.

As reported in Doctor Yourself, by Andrew Saul, PhD (Basic Health/publisher), treatment with topical Vitamin E (twice daily, open up Vitamin E capsule and squeeze Vitamin E out and apply to the site) has also been successful for some individuals.

Medical treatments

Some people require the following medical treatments for chronic or severe hemorrhoids:

• Rubber band ligation: sometimes called Baron ligation. Elastic bands are applied onto an internal hemorrhoid to cut off its blood supply. Within several days, the withered hemorrhoid is sloughed off during normal bowel movement.
• Hemorrhoidolysis/Galvanic Electrotherapy: desiccation of the hemorrhoid by electrical current.
• Sclerotherapy (injection therapy): sclerosant or 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. Rarely used anymore because of side effects.
• Laser, infrared or BICAP coagulation: laser, infrared beam, or electricity is used to cauterize the affected tissues. Lasers are now much less popular. Infrared coagulation has been studied in comparison with RBL and found to be as effective in hemorrhoids up to grade III. These are the most readily available non-surgical procedures in the US.
• Hemorrhoidectomy: a true surgical procedure to excise and remove hemorrhoids. Has possible correlation with incontinence issues later in life; in addition, many patients complain that pain during recovery is severe. For this reason is often now recommended only for severe (grade IV) hemorrhoids.
• Stapled Hemorrhoidectomy: Also called the procedure for prolapse and hemorrhoids, it is designed to resect 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.
• Enema: This Practice is only used to clean the rectum in some cases and should only be done by a doctor. Water is injected into the rectum and then flushed out cleaning the area.
• Doppler Guided Hemorrhoidal Artery Ligation : The only evidence based surgery for all grades of hemorrhoids. It does not involve cutting tissues or even a stay at the hospital; patients are usually back to work on the same day. It is the best treatment for bleeding piles, as the bleeding stops immediately. (This reference was added by a doctor who specializes in this technique, and the reference links to his site.)

Diseases with similar symptoms

Symptoms associated with rectal cancer, anal fissure, anal abscess, anal fistula, 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 40 (30 with family history of bowel cancers); a clear (normal) scope is good for 10 years.

Trivia

• The novelist Anthony Burgess, who suffered from hemorrhoids, humorously referred to the condition as the Writer's Evil.
• During the 1980 World Series, George Brett made headlines for reasons other than his play on the field. After leaving Game 2 in the 6th inning due to hemorrhoid pain, Brett had minor surgery the next day, and in Game 3 returned to hit a home run as his Royals wound up winning in 10 innings by the score of 4-3. (In 1981 he would miss two weeks of spring training to have his hemorrhoids removed.)

See also

• Anal fissure

External links

• NIDDK-NIH Hemorrhoid
• MEDLINEplus Hemorrhoids
• Hemorrhoids In Plain English
• American Society of Colon & Rectal Surgeons
• Videos of Hemorrhoidectomy being performed
• Effectiveness of different hemorrhoids treatment methods