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

ANAL ABSCESS

Anal Abscess Overview

A perirectal abscess is a collection of pus in the deep tissues surrounding the anus. By contrast, a perianal abscess is a shallower collection of pus under the skin surrounding the anus; however, both are sometimes described as an anal abscess. Both types of abscesses need immediate medical attention; however, a perirectal abscess usually is the more severe infection. A delay in treatment may cause serious worsening of the condition and unnecessary complications.

Anal Abscess Causes

Perirectal and perianal abscesses are thought to develop from the glands surrounding the anus; on occasion, perianal abscesses may develop from infected skin adjacent to the anus. Glands may plug up, usually leading to bacterial infection. When the glands fill with pus, they may burst inward, releasing their infected contents into the spaces around the rectum and anus. This pus causes an abscess, or pus collection, in the spaces surrounding the rectum or anus. The anal abscess may enlarge, causing pain, fever, and difficulty with bowel movements.
Certain people are more likely to develop perirectal and perianal abscesses, including those with the following medical conditions:

• Diabetes
• AIDS or HIV infection with low white blood cell counts
• Crohn's disease
• Persons on medications that suppress the body's immune system, such as steroids (prednisone, methylprednisolone), or those undergoing chemotherapy for cancer
• Pregnancy
• Placement of foreign bodies into the anus
• Sexually transmitted diseases
• anal fissures

  Anal Abscess Symptoms

  Signs and symptoms of perirectal and perianal abscesses include the following:
• Pain in the anal area or buttocks
• Pus drainage near the anus
• Fever
• A lump in the anal area
• Painful bowel movements
• Lower abdominal pain
• Fatigue
• Swelling in the anal area or buttocks
• Night sweats

When to Seek Medical Care

If a person suspects they have a perirectal or perianal abscess they should see a health care practitioner. The diagnosis is not always easy to make, and the health care practitioner may need to do tests or consult with specialists.
Go to an emergency department when you have any of the following symptoms:

• High fever or shaking chills
  
  
• Significant rectal/anal pain
  
  
• Inability to have a bowel movement, or a painful bowel movement
  
  
• Persistent vomiting
  
  
• Any other unusual signs or symptoms that may indicate an emergency condition

Anal Abscess Diagnosis

The health care practitioner will ask questions about the patient's condition. Give the health care practitioner all necessary information. Discussing the details may be embarrassing, but health care practitioners and other medical personnel are required to maintain confidentiality. Honest responses to the health care practitioner's questions will help provide the patient faster appropriate care.

• The health care practitioner will then examine the patient and should explain the parts of the exam may be uncomfortable and will be careful to protect the patient's modesty.

• The health care practitioner should provide clear answers to any questions the patient asks; they should understand the treatment plan.

• Sometimes the diagnosis is obvious, and no tests are needed. At other times, blood and urine tests and special imaging tests such as X-ray, CT scan, MRI, and ultrasound may be needed. The health care practitioner may also consult other specialists to confirm the diagnosis or to come up with the best treatment plan.

acetaminophen (Tylenol and others), may help control the pain and fever.

• If the abscess opens by itself there will be a release of pus, and possibly some relief of pain and fever. Regardless, the abscess are still should be examined by a health care practitioner.

• Even if the symptoms improve with home care, the affected individual should seek medical attention. Abscesses need to be evaluated and treated by a health care practitioner. They rarely resolve on their own. Many people need further special treatment, especially with perirectal abscesses, to avoid complications or a return of the abscess.

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  nal Abscess Medical Treatment

  Depending upon the severity of the abscess and any other medical problems, treatment may be accomplished on an outpatient or inpatient basis. The treatment plan should be explained to the patient in detail.
• Minor surgery may be performed in the health care practitioner's office or in the emergency department using local anesthesia (an injection in the infected area), and possibly IV sedation. Most patients are referred to a surgeon for treatment of perirectal abscesses because the abscess may involve additional structures or require more debridement that may not be apparent until it is surgically explored. Patients should be able to go home when they awake and will be given prescription pain medication for the first few days with some uncomplicated abscesses.

• Alternatively, the surgery may be done in the operating room by a surgeon using spinal anesthesia (the patient is awake and numb from the waist down) or general anesthesia (patient is "asleep" under sedation). The hospital stay may be overnight or several days.

• Admission to the hospital may be required with an IV line for fluids, antibiotics, and pain medicine.

• Patients may need an update of their tetanus booster, if this has not been done in the past 5-10 years.

• Blood and other tests may need to be repeated to evaluate the patient's progress after treatment.

Anal Abscess Follow-up

Patients may have pain for several days following surgery, but should improve over time.

• Patients may not have stitches. Infected wounds such as abscesses are left open to drain. If they were stitched shut they would just fill with pus again. There may be packing left in the wound, which usually will be removed by the health care practitioner after a few days.

• Patients may need to take an antibiotic and pain medication for several days, depending on their condition.

• Using stool softeners and adhering to good hygiene, such as sitz baths after every bowel movement, decreases the patient's discomfort and helps recovery.