Hemorrhoids: A Review

 

AR Mullaicharam1, R Uma Maheswari2, K Geetha2, Preetha S Panicker2 and V Chandralekha2

1Oman  Medical College, Muscat

2Ultra college of Pharmacy, Madurai-20.

*Corresponding Author E-mail: r.uma2003@gmail.com

 

ABSTRACT

Anorectal disorders are common and the majority of the population will experience one at some time during their lives. There has been a steady increase in the prevalence of sexually transmitted diseases in recent decades leading to the identification of new anorectal syndromes. The prevalence of these conditions is increasing Hemorrhoidal disease is very widespread in modern industrial society. Hemorrhoids (piles) are common in both men and women and have a tendency to run in families. They may occur at all ages, but are uncommon below the age of 20 years except for vascular malformation (defect information of blood vessels) which may occur in Children. Hemorrhoids (Greek ‘haima’ means blood and ‘rhoos’ means flowing) or piles (Latin: Pila means a ball) refers to dilated veins occurring in relation to the anus. Hereditary predisposition, low-fibre diet, constipation and abnormal bowel habits are believed to play an important role in pathogenesis of hemorrhoids. This article highlights causes, types, symptoms , diagnosis, management  of  haemorroids

 

KEYWORDS:

 


INTRODUCTION:

Anorectal disorders1 are common and the majority of the population will experience one at some time during their lives. Patients with anorectal disorders seek medical sscare primarily because of pain, rectal bleeding, or change in bowel habits. Other common complaints are protrusion of hemorrhoids, anal discharge, perianal itching, swelling, anal tenderness, stenosis and ulceration, constipation results from delaying defecation because of anorectal pain.

 

There has been a steady increase in the prevalence of sexually transmitted diseases in recent decades leading to the identification of new anorectal syndromes. The prevalence of these conditions is increasing. This syndromes include veneral infections such as syphilis, gonorrhea, herpes, Chlamydia and candidiasis and they are most commonly seen in male homo sexuals who practice anorectal inter course.

 

Hemorrhoidal disease2 is very widespread in modern industrial society. Hemorrhoids (piles) are common in both men and women and have a tendency to run in families. They may occur at all ages, but are uncommon below the age of 20 years except for vascular malformation (defect information of blood vessels) which may occur in children. By the age of fifty about 50% of the people tend to develop hemorrhoids to some extent.

 

Hemorrhoids:

Hemorrhoids (Greek ‘haima’ means blood and ‘rhoos’ means flowing) or piles (Latin: Pila means a ball) refers to dilated veins occurring in relation to the anus. Hereditary predisposition, low-fibre diet, constipation and abnormal bowel habits are believed to play an important role in pathogenesis of hemorrhoids.

 

Symptoms of hemorrhoids include bleeding, perianal itching, anal discomfort, anal pain and anal discharge. These symptoms may often be quite distressing to the extent of significantly compromising with the quality of life in patients of hemorrhoids. Lack of awareness about the disease and failure to comply with the medical advice only serves to aggravate the condition further and increase the risk of relapse.

 

Hemorrhoids are dilated3 portions of veins in the anal canal. Shearing of the mucosa during defecation results in the sliding of the structures in the wall of the anal canal, including the hemorrhoidal and vascular tissues. Increased pressure in the hemorrhoidal tissue due to pregnancy may initiate hemorrhoids (or) aggravate existing ones.

 

Types of Hemorrhoids:

Depending upon its origin, hemorrhoids (piles) can be divided into two types.

1.                Internal hemorrhoids:

Internal hemorrhoids are so called because they develop inside the anus. They are usually painless because they are not richly supplied by nerves. Internal hemorrhoids may or may not bulge out (protrude) through the anal opening. When protruding outside, the appearance of such hemorrhoids may resemble a bunch of grapes.

 

Depending upon the degree of protrusion, the internal hemorrhoids can be divided into

a)                First degree hemorrhoids

Hemorrhoids in which the dilated veins remains entirely within the anal canal and do not bulge out of the anal opening.

b)                Second degree hemorrhoids

In later stage, the hemorrhoids may protrude during the passage of stool but they recede (draw back) spontaneously through the anal opening on their own.

c)                Third degree hemorrhoids

As the disease progresses, the hemorrhoids may protrude during the passage of stool but do not recede back on their own and have to be replaced by hand.

d)                Fourth degree hemorrhoids

In still advanced cases, the hemorrhoids may protrude any time of the day (i.e even without  passage of stool) especially if the person is tired (or) exerts himself and remain permanently protruded (or) prolapsed.

 

2.                External hemorrhoids:

External hemorrhoids develop at the margins of the anal opening and can be seen outside (hence known as external piles). These are usually painful because they are richly supplied by nerves. When both the external and internal varieties are present together the condition is known as intero external hemorrhoids.

 

CAUSES OF HEMORRHOIDS:

Hemorrhoids are caused due to an increased pressure in the abdomen. The factors which may be responsible for this include;

·                  Constant straining at stool due to long standing constipation.

In case of constipation the stools are very hard. Therefore the rectum has to push harder to get the stool out. This can cause not only an increased pressure on the rectal blood vessels but also trauma to the rectum (due to passage of hard stool) resulting in swelling of the blood vessels.

·                  Diet high in processed food and low in fiber (noodles, cold drinks, fried food etc)

·                  Laxative abuse and frequent enemas

·                  Repeated episodes of diarrhea

·                  Secondary life style:      people who do not exercise are more prone to gain weight and develop constipation.

·                  Heredity:  Hemorrhoids are frequently seen in the members of the same family presumably  due to  weakness of vein walls since birth.

·                  Obesity

·                  Occupations involving lot of traveling (e.g. Marketing and sale professionals) tends to suppress the natural urge for bowel evacuation. This could result in constipation and eventually piles.

·                  Occupations involving prolonged standing (eg: traffic police, waiters etc)

·                  Lifting heavy objects

·                  Repeated coughing and sneezing

·                  Pregnancy

 

Hemorrhoids are a common problem during pregnancy. Roughly about 50% females may suffer from this problem and it usually occurs after the second trimester (i.e. 13-28 weeks of pregnancy) The pressure of the fetus in the abdomen and certain hormonal changes cause the blood vessels around the anus to enlarge.

·                  Some diseases / conditions that may cause hemorrhoids include enlarged prostate, urethral stricture (narrowing of the urinary opening) and cancer of rectum.

 

SYMPTOMS OF HEMORRHOIDS:

Manifestations of hemorrhoids may vary depending upon the type of hemorrhoid4

 

Common symptoms of Internal hemorrhoid include:

·                  Bleeding

Bleeding while passing the stool is usually the only symptom in early stages of hemorrhoids. The bleeding is slight it is bright red in color and occurs with passage of stool as a “splash in the pan

·                  Prolapsed:

Prolapse of hemorrhoids is usually a later symptom. In the beginning, hemorrhoids may protrude during the passage of stool but they recede (draw back) through the anal opening on their own. As the condition further progresses, hemorrhoids do not recede back and have to be replaced by hand. In more advanced stages, hemorrhoids may bulge out anytime during the day, even without defecation (passing stool) especially when person is either tired or exerts himself. It results in a feeling of discomfort and heaviness in the rectum.

·                  Anal discomfort:

Feeling of vague anal discomfort usually accompanies bleeding in early stages of hemorrhoids. This discomfort increases when hemorrhoids enlarges or protrudes through the anal opening.

 

·                  Anal discharge:

A mucoid (slimy) discharge and fecal leakage usually accompanies prolapsed hemorrhoids.

 

·                  Perianal itching:

Itching in an around the anal area is a common distressing symptom which invariably follows mucoid discharge from the prolapsed hemorrhoids.

 

·                  Pain:

Pain is not a common feature in internal hemorrhoids unless complicated by thrombosis , infection or erosion of the inner lining of the anal canal (mucosa)

·                  Anemia:

Anaemia is uncommon in hemorrhoids. However it may rarely be present in long standing cases due to profuse bleeding from hemorrhoids.

 

Common symptoms of External hemorrhoids include

·                  Pain:

External hemorrhoids are quite painful because they lie under the skin which is richly supplied by nerves.

·                  Swelling:

External hemorrhoids may appear as a tender blue swelling at the anal margin due to thrombosis (formation of blood clot) veins in the external plexus. Since the blood clot usually lies at the level of external sphincter muscles, anal spasm often occurs.

 

In some cases of external hemorrhoids, bleeding and perianal itching (itching in and around anus) may also occur due to co-existence of internal hemorrhoids, passage of hard stools or poor anal hygiene.

 

DIAGNOSIS OF HEMORRHOIDS:

Diagnosis of and internal5 external hemorrhoids is made on the basis of history of complaints ,inspection, digital examination and direct visualization through proctoscope. A thorough evaluation is important any time bleeding from the return or blood in the stool lasts more than a couple of days.

·                  History of complaints

Fresh bleeding (bright red blood) per rectum like a splash in the pan, anal discomfort, anal discharge, perianal itching etc may be suggestive of hemorrhoids.

·                  Digital examination

Digital examination of anal canal is done to ascertain the tone of external sphincters, pain or tenderness and any thickening in the wall of the anal canal.

·                  Proctoscopy

Proctoscopy is an instrument used to visualize the interior of the anal canal and the rectum, Internal hemorrhoids, anal fissure and any growth can be seen through protoscope if present.

·                  Sigmoidoscopy / Colonoscopy

Visualization of anal canal, rectum and sigmoid colon (lower part of large intestine) through sigmoidoscope and entire colon (Large intestine) through colonoscope is done to rule out other significant causes of bleeding per rectum (like cancer of rectum and colon, ulcerative colitis, crohn’s disease).

 

MANAGEMENT OF HEMORRHOIDS:

Once diagnosis of hemorrhoids has been made, the next step would be to relieve the symptoms accordingly for which the following measures are usually taken:

·                  Oral preparations (flavonoids, diosmin etc) strengthen the venous tone and act on veins to reduce venous stasis and venous distension. They may also play a role in normalizing capillary per meability.

               Local preparations (Creams, ointments) containing anti-septic, astringents (toughens the surface) (or) vasoconstrictors (that constricts the blood vessels) may provide relief from itching ,pain, swelling and bleeding when applied topically to the affected area.

·                  Use of stool softeners:     Which may help in relieving constipation by softening the stools and promoting easy and comfortable evacuation.

·                  Simple dietary changes such as increasing the amount of fiber ( such as raw vegetables, whole grain breads and cereals, prunes, raisins, pop corn) and fluid (6-8 glasses of water daily) in the diet can be enough to prevent constipation and ease the symptoms.

·                  Sitz baths: Fomentation of local area has been found to be useful. The patient is asked to sit over a tub filled with lukewarm water. The tub should be filled up to the brim. The temperature of water should be as hot as the skin in an around the affected area                           

·                  can tolerate. This process can be tried for 10-15 minutes at a time and can be repeated up to 4-5 times a day.

·                  Application of cold compresses around the anal region with the use of ice has also been found to be helpful.

·                  Maintenance of hygiene in the anal area is an important aspect in management of hemorrhoids. Anal region, being moist, is prone to infections. Therefore this area should be kept clean and dry.

·                  Some life style modifications can also help in hemorrhoids.

·                  The urge for bowel movement should not be ignored

·                  Avoiding excessive straining at stools

·                  Avoiding lifting heavy objects

·                  Avoiding smoking

·                  Regular physical activity of at least 25-30 minutes (eg: brisk walking) can also help in easing the condition

 

In case of severe hemorrhoids, any one of the following non-operative procedures may be advised.

·                  Sclerotherapy or injection treatment

This treatment is advised for first degree internal hemorrhoids. A chemical solution is injected in to the hemorrhoids which then interferes with the blood supply to the hemorrhoids causing them to shrink. A protoscope is introduced until the hemorrhoid has almost disappeared from the lumen and only its upper end is visible. The injection is made at this point above the main mass ofeach hemorrhoid in to the submucosa at or just above the anorectal ring using a disposable needle with the level of the needle directed towards the rectal wall from 3 to 5ml of phenol in almond oil injected. There is slight transient bleeding from the point of puncture. The injection is painless, but a dull ache is common for a few hours. There is no special treatment. If only one hemorrhoid is present it may be treated by one injection; if all three hemorrhoids are equally enlarged each is injected at the same session. Often three session at 6 weekly intervals are required case should be taken not to inject into the prostate anteriorly, for the resulting prostatitis can be crippling.

 

·                  Rubber band ligation (or) Banding treatment

Second degree hemorrhoids which are too large to be successfully treated by injection therapy, can be treated by this method. A rubber band is passed around the base of the pedicle (stalk) of each hemorrhoid with the special instrument. The band cuts off the blood supply resulting in shrinking and falling off of hemorrhoids. Not more than two hemorrhoids should be banded at each session and 3 weeks at least should elapse between each treatment. The procedure is usually painless and can be performed in the out- patient department

·                  Cryosurgery:

Application of liquid nitrogen can cause coagulation necrosis of the hemorrhoids which tends to subsequently separate and drop-off. This technique however often causes troublesome mucus discharge and pain.

·                  Photocoagulation:

Application of infrared or laser coagulation by a specially designed instrument has been advocated for the treatment of early hemorrhoids. In this procedure the hemorrhoids are burned by laser (or) infrared light.

·                  Trans anal Doppler Hemorrhoids dearterialization

A novel alternative to operative hemorrhoidectomy, it involves inserting the “Doppler modified proctoscope” into the anorectum to identify the hemorrhoidal arteries that need to be ligated (tied up). Ligation reduces blood supply to the hemorrhoidal tissue and results in shrinking of the hemorrhoids.

 

Operative treatment (or) surgical removal of hemorrhoids (hemorrhoidectomy) is done only in advanced cases. Indications of hemorrhoidectomy includes.

·                  Failure of injection therapy and banding treatment

·                  Third and fourth degree hemorrhoids

·                  Fibrosed hemorrhoids

·                  External hemorrhoids

 

Hemorrhoidectomy:

Surgical removal of hemorrhoids is known as hemorrhoidectomy. Usually two methods are followed in hemorrhoidectomy. Open and closed. In open hemorrhoidectomy the hemorrhoid is ligated and excised but the anal mucosa and skin are left open to heal. In closed technique the hemorrhoid is ligated and excised but the anal mucosa and skin is sutured.

 

Complications of hemorrhoidectomy include

·                  Pain

·                  Retention of Urine

·                  Hemorrhage

·                  Anal Stricture

·                  Anal Fissure

 

Do’s and Don’ts6:

Do’s:

·                  The first precaution to be taken by a piles (hemorrhoids) patient is to prevent constipation and straining.

·                  Take adequate fiber in the diet. Fresh fruit, raw and cooked vegetables, whole grain breads and cereals, prunes, raisins, pop corn, figs. Pears and beans are rich sources of fiber.

 

·                  The fiber content in diet should be increased gradually, as sudden increase in fiber intake can cause diarrhea as well as pain in stomach.

·                  Try fiber supplements (as advised by the doctor) to keep the stool soft and regular. Drink plenty of fluids (at least 8-10 glasses of water daily)

·                  Reduce the intake of coffee, tea and spicy food as they may act as irritants and cause pain during bowel movement. Lose weigh, if you are overweight.

·                  Exercise regularly as it helps to improve blood circulation as well as keep the extra calories off. Train yourself for a regular bowel movement.

·                  Use stool softners, which may help in softening the stools.

·                  If suffering from cough or sneezing bouts (they too tend to increase the intra abdominal pressure) get immediate treatment from the doctor.

 

Don’ts:

·                  Do not ignore an urge for bowel movement

·                  Avoid excessive straining at stool.

·                  Do not sit in the toilet for long periods.

·                  Do not use laxatives regularly as it may become a habit and cause the bowels to lose its ability to function normally.

·                  Avoid lifting heavy objects. Even if you lift anything heavy exhale and do not hold your breath.

·                  Avoid sitting for long periods as this can exert pressure in the anal area and aggravate the problem of piles (hemorrhoids). Even if your job requires continuous sitting, take short breaks in between and walk around for sometime. This will ease the pressure in the anal area.

·                  Keep the anal area clean using a very soft or moist toilet paper after motion. This will help in relieving itching and prevent further swelling.

 

CONCLUSION:

Hemorrhoids refers to dialated veins in relation to anus .Hereditary disposition, low fiber diet, constipation and abnormal bowel habits plays a vital role in the pathogenisis of hemorrhoids. Main symptoms include anal pain, discomfort and bleeding  sliding and shearing of the mucosa during defecation results.

 

Lack of awareness and failure to comply with the disease may aggravate the condition and increase the further risk of relapse. This article highlights the prevalence of disease along with diagnosis and treatment schedule, which may prove useful in creating awareness and to prevent relapse.

 

REFERENCES:

1.       Brunner and suddarth’s Text book of Medical Surgical Nursing, Eleventh Edition

2.       Bailey and Love”s short practice of surgery 23rd edition.

3.       Sabiston Text book of surgery, 18th edition

4.       Harrison’s principles of Internal Medicine, 14th edition

5.       Kathryn. L. Mecance and sue E. Hurther pathophysiology. The biologic  basis for disease in adults and children.

6.       http//www.pubmed.com

 

 

 

Received on 24.03.2009       Modified on 20.05.2009

Accepted on 12.07.2009      © RJPT All right reserved

Research J. Pharm. and Tech. 3(2): April- June 2010; Page 296-299