HAEMORRHOIDS

haemorrhoid Overview

Hemorrhoids are enlarged veins located in the lower part of the rectum and the anus. They become swollen because of increased pressure within them, usually due to straining at stools and during pregnancy because of the pressure of the enlarged uterus.

Internal hemorrhoids are located in the inside lining of the rectum and cannot be felt. They are usually painless and make their presence known by causing bleeding with a bowel movement. Internal hemorrhoids can prolapsed or protrude through the anus.

External hemorrhoids are located underneath the skin that surrounds the anus. They can be felt when they swell and may cause itching or pain with a bowel movement, as well as bleeding. A thrombosed external hemorrhoid occurs when blood within the vein clots, and can cause significant pain.

Hemorrhoid Causes

Hemorrhoids are associated with constipation and straining at bowel movements. Pregnancy is also associated with hemorrhoids. These conditions lead to increased pressure within the hemorrhoidal veins causing them to swell. Other conditions, for example chronic liver disease, may also cause increased venous pressure and may be associated with hemorrhoid formation. Hemorrhoids are very common and are estimated to occur in up to one-half of the population by age 50.

Hemorrhoid Symptoms

The most common symptom and sign from hemorrhoids is painless bleeding. There may be bright red blood on the outside of the stools, on the toilet paper, or dripping into the toilet. The bleeding usually is self-limiting.

Bleeding with a bowel movement is never normal and should prompt a visit to a health care practitioner. While hemorrhoids are the most common cause of bleeding with a bowel movement, there may be other reasons to have bleeding including inflammatory bowel disease, infection, and tumors.

Prolapsed Internal Hemorrhoids

Prolapse of an internal hemorrhoid occurs when the internal hemorrhoids swell and extend from their location in the rectum through the anus. A prolapsed internal hemorrhoid:

• can be felt as a lump outside the anus;
• can be gently pushed back through the anus, this may resolve the problem of prolapse but does not fix the hemorrhoid itself;
• may enlarge and swell even more if they cannot be pushed back;
• may become entrapped, which requires medical attention.

Hemorrhoids may also cause pruritus ani or itching around the anus, and a constant feeling of needing to have a bowel movement.

Thrombosed External Hemorrhoids

Thrombosed external hemorrhoids are a painful condition. These occurs when a blood clot develops in the hemorrhoid causing swelling and inflammation.

• When a blood clot occurs in a hemorrhoid, the hemorrhoid will become even more swollen. This swelling leads to increased pain.
• The pain is usually worse with bowel movements and may increase with sitting.
• Thrombosed external hemorrhoids often need medical care and treatment.

When to Seek Medical Care

When to call the doctor

• Bleeding from the rectum or anus is never normal and although hemorrhoids are the most common reason to have blood in the stool, it should be discussed with your primary health care practitioner. Other causes of rectal bleeding exist and can be serious. Inflammatory bowel disease and cancers of the colon can present with rectal bleeding.
• Medical care should be sought urgently if a person is taking anticoagulation medication such as warfarin (Coumadin), clopidogrel (Plavix), or prasugrel (Effient).
• Individuals who have associated symptoms such as lightheadedness and weakness may have significant blood loss and may require more urgent care.
• Hemorrhoids do not cause abdominal pain; should this be present with bleeding, medical care should be accessed immediately.
• Prolapsed hemorrhoids that cannot be pushed back through the anus require medical care.
• Thrombosed external hemorrhoids may cause significant pain and medical care may need to be sought.

Exams and Tests

Diagnosis of hemorrhoids is usually made by history and physical examination by the health care practitioner. Depending upon the situation, past medical history, medications and stability of the patient, treatment may follow with no further testing.

Inspection of the anus and a digital rectal examination are often performed. Sometimes anoscopy may be required where a small, lighted scope is introduced into the anus to examine the inner lining of the anus and rectum. The procedure is often performed in the office without sedation. If there is the potential that the bleeding source originated above the rectum from other parts of the colon, sigmoidoscopy or colonoscopy by a gastroenterologist may be recommended.

If there is concern that significant bleeding has occurred, a CBC (complete blood count) to measure hemoglobin and hematocrit levels is obtained. If the patient is on warfarin (Coumadin), a prothrombin time (PT) or INR may be done to measure the blood clotting levels.

Hemorrhoid Treatment

Self-Care at Home

Symptomatic treatment for hemorrhoids can be done at home.

Warm Sitz Baths

• Sitting in a few inches of warm water three times a day for 15-20 minutes may help decrease the inflammation of the hemorrhoids.
• It is important to dry off the anal area completely after each Sitz bath to minimize irritation of the skin surrounding the anus.

Dietary Changes

• Increased fluid intake and dietary fiber (roughage) will decrease the potential for constipation and lessen the pressure on the rectum and anus during a bowel movement, minimizing further swelling, discomfort, and bleeding. Dietary fiber supplements may also help bulk up the stools

Stool Softeners

• Stool softeners may help but once hemorrhoids are present, liquid stools may cause inflammation and infection of the anus. Your health care practitioner and pharmacist are good resources to discuss their use.

Activity Suggestions

• Individuals with hemorrhoids should not sit for long periods of time and may benefit from sitting on an air or rubber donut available at most local pharmacies.
• Exercise is helpful in relieving constipation and in decreasing pressure on the hemorrhoidal veins. Individuals should be encouraged to have a bowel movement as soon as possible after the urge arises. Once that urge passes, stools can become constipated and straining with a bowel movement may occur.

Over-the-Counter Medications

• Many creams, ointments, and suppositories are available for symptom relief and may be used for comfort. However, they do not "cure" hemorrhoids. Often they contain a numbing medication or a corticosteroid to decrease inflammation and swelling.

Medical Treatment

Prolapsed Internal Hemorrhoids

• Most prolapsed internal hemorrhoids can be pushed back into the anus but occasionally your care provider may need to reduce them by gently pushing them with constant pressure.
• If the hemorrhoids remain swollen and trapped outside the anus and nothing is done about it, the hemorrhoid tissue may not receive enough blood and can become infected. In such situations, surgery may be required to resolve the problem.

Thrombosed Hemorrhoids

• Thrombosed external hemorrhoids can be painful and are associated with a hard lump that is felt at the anus and cannot be pushed back inside. Most often the clot within the hemorrhoid will need to be removed with a small incision.
• After local anesthetic is placed under the skin surrounding the hemorrhoid, a scalpel is used to cut into the area and the clot is removed. There is almost instant relief of the sharp pain but a dull ache may continue.
• There may be some mild bleeding from the hemorrhoid for a couple of days. Sitz baths and over-the-counter pain medications may be recommended.
• The use of a rubber or air rubber donut may help with the pain as well. Preventing constipation is also a priority.

Surgery

A variety of surgical options exist for persistent pain or bleeding.

Rubber band ligation: Rubber band ligation of internal hemorrhoids can be done in the office. The surgeon places a couple of tight rubber bands around the base of the hemorrhoidal vein causing it to lose its blood supply. There may be some fullness or discomfort for 1-2 days after the procedure and a minor amount of bleeding may be experienced.

Sclerotherapy: Sclerotherapy describes a procedure when a chemical is injected into the hemorrhoid causing it to scar.

Laser therapy: Laser therapy can be used to scar and harden internal hemorrhoids.

Hemorrhoidectomy: Hemorrhoidectomy is a surgical procedure done in the operating room with an anesthetic agent (general, spinal or local with sedation) where the whole hemorrhoid is removed (ectomy=removal). This is the most aggressive approach and there is a markedly decreased chance of the hemorrhoids returning. However, there is also an increase in the complication rate.

Stapled hemorrhoidectomy: Stapled hemorrhoidectomy is the newest surgical technique for treating hemorrhoids, and it has rapidly become the treatment of choice for third-degree hemorrhoids. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward. Stapled hemorrhoidectomy is faster than traditional hemorrhoidectomy, taking approximately 30 minutes. It is associated with much less pain than traditional hemorrhoidectomy and patients usually return earlier to work.

Regardless of the surgery, Sitz baths and dietary suggestions for increased roughage are usually recommended.

Next Steps

Follow-up

Warm Sitz baths, plenty of fluids and increased roughage are usually recommended. Hemorrhoidal pain is usually managed with over-the-counter pain relievers.

Stool softeners may be recommended by your health care practitioner. The person should contact their health care practitioner if they develop increased rectal pain, bleeding, fever, abdominal pain, or vomiting after hemorrhoid treatment.

Prevention

The risk of hemorrhoids can be decreased by eating a high fiber diet, staying well hydrated, getting regular exercise, and trying to have a bowel movement as soon as possible after the urge arises.

Outlook

Most people with hemorrhoids have an excellent prognosis. While symptoms of bleeding or discomfort may flare from time to time, they don't last long and can be relieved with symptomatic care at home.

Topic Overview