Hemorrhoids

Internal Hemorrhoids. Source: Wikimedia Commons.

Hemorrhoids are swollen, inflamed veins in the anus or rectum. They result from straining during bowel movements, chronic constipation or diarrhea, or pregnancy. Hemorrhoids can cause rectal bleeding, pain and itching. They are very common and, aside from discomfort, do not usually cause significant problems.

Other Names

• Piles

Types

Diagram of the anus and rectum. The dentate line is visible, although not labeled. Source: National Institutes of Health.

Hemorrhoids are categorized as either internal or external.

Internal

Internal hemorrhoids are located above an anatomical landmark inside the anal canal called the dentate line. They are covered by a mucus membrane. Internal hemorrhoids usually cause less discomfort than external hemorrhoids, and patients may not even know they have them. Internal hemorrhoids are categorized by the degree of their severity.

• First degree hemorrhoids are enlarged but not prolapsed (they do not stick out of the anus) and usually have no symptoms.
• Second degree hemorrhoids prolapse (stick out of the anus) during defecation but easily return to usual position.
• Third degree hemorrhoids prolapse with bowel movement and exertion.
• Fourth degree hemorrhoids are permanently prolapsed and are the most likely kind to cause pain and bleeding.

External

External hemorrhoids are located below the dentate line. They may cause pain and itching and may become thrombosed (a blood clot may form in the vein).

Mixed

Mixed hemorrhoids are a combination of internal and external hemorrhoids.

Signs and Symptoms

Although many people have hemorrhoids, not all experience symptoms. Common symptoms of internal hemorrhoids are bleeding, pain, and pruritis (itchiness). Bright red blood can typically be found on toilet paper or in the toilet bowl. An internal hemorrhoid may protrude through the anus to the outside of the body, becoming irritated and painful. This is known as a prolapsed hemorrhoid. Severe pain is not typical of an internal hemorrhoid but may be seen with a thrombosed external hemorrhoid.

Symptoms of external hemorrhoids may include painful swelling, or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid.

Other anorectal disorders, including anal fissures, fistulae, or abscesses can cause similar symptoms and may be incorrectly referred to as hemorrhoids. Hemorrhoids typically are not dangerous or life-threatening. In most cases, hemorrhoidal symptoms resolve on their own within a few days.

Causes

The lower portion of the rectum, or anus, is composed of cushions that contain a system of veins and some supporting tissue. During defecation, these veins fill with blood, providing a cushion to the anal canal. If a person pushes hard to move stool, the veins supplying the anus become dilated and the supporting cushion is pushed down. This happens because the supporting tissue has deteriorated due to extensive downward pressure from excessive straining. Other contributing factors to hemorrhoids include chronic constipation or diarrhea, aging, and pregnancy.

Diagnosis

A thorough evaluation and proper diagnosis is important any time bleeding from the rectum or blood in the stool occurs. Bleeding from the rectum may also be a symptom of other digestive diseases, including colorectal cancer.

In a physical exam, a doctor detects hemorrhoids by examining the anus and rectum to look for swollen blood vessels. The doctor will need to insert a gloved, lubricated finger into the rectum to feel for abnormalities.

Closer evaluation of the rectum for hemorrhoids may require an exam with an anoscope, which is a short, hollow plastic tube with a light that is used to see internal hemorrhoids. A proctoscope is used for more complete examination of the entire rectum.

To rule out other causes of gastrointestinal bleeding, the doctor examines the rectum and lower colon, or sigmoid, with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.

Treatment

Relieving the symptoms

Initial medical treatment of non-thrombosed hemorrhoids targets symptom relief. Below are some measures to reduce symptoms:

• Sitz baths several times daily with warm water for 10 minutes. This improves hygiene.
• Hemorrhoidal cream or suppository application to the affected area to reduce inflammation.
• Stool softeners to reduce constipation and straining.

Procedures

In some cases, hemorrhoids must be treated endoscopically or surgically. These methods are used to remove the hemorrhoidal tissue. These procedures are performed during an office or hospital visit.

A number of methods may be used to remove or reduce the size of internal hemorrhoids. These techniques include the following

• Rubber band ligation. A rubber band is placed around the base of the hemorrhoid inside the rectum to cut off circulation.
• Sclerotherapy. A chemical solution is injected around the blood vessel to obliterate the hemorrhoid.
• Infrared Coagulation. A special device is used to cauterize or burn hemorrhoidal tissue.
• Other non-operative treatments: cryotherapy, bipolar diathermy, direct current therapy
• Hemorrhoidectomy. Hemorrhoidectomy is the surgical removal of hemorrhoids, which is needed in cases of prolapse, persistent pain and bleeding. These techniques may be used for extremely painful, thrombosed hemorrhoids.

This YouTube video shows rubber band ligation of an internal hemorrhoid.

Holistic and alternative treatments

Topical astringents such as witch hazel and aloe vera may help with itching and irritation.

Products which reportedly strengthen the veins of the anus, rectum or colon include:

• Blackberries
• Blueberries
• Cherries
• Vitamin C
• Chamomile tea

Efficacy and safety in these products is unknown to medical science.

Ruscus aculeatus (butcher's broom) has been studied in women in chronic venous insufficiency in the legs, and found to be safe and effective over a 12-week period. ^[1] Because hemorrhoids are veins too, the herb might be helpful in hemorrhoids, It has been traditionally used in the treatment of hemorrhoids.^[2], but has not been scientifically studied for this purpose.

Prevention

The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining. Emptying the bowels as soon as possible also helps. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing softer stools.

Preventing the recurrence of hemorrhoids requires relief of the pressure and straining of constipation. Doctors will often recommend increasing fiber and fluids in the diet, although some authors have challenged the recommendation to eat more fiber.^[3] Eating the right amount of fiber and drinking plenty of fluid (not alcohol, which can be dehydrating) results in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding.

Good sources of fiber are fruits, vegetables, and whole grains. In addition, doctors may suggest a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel).

Chances of Developing Hemorrhoids

Hemorrhoids are common in both men and women. Half of the population has had hemorrhoids at some point by the age of 50 years. At any given time, approximately 4% of the U.S. population has hemorrhoids.^[4] Prevalence is greater in higher socioeconomic classes and among Caucasians compared to African Americans.

Hemorrhoids are common among pregnant women. The pressure of the fetus on the abdomen along with hormonal changes cause the hemorrhoidal vessels to dilate. These vessels are also placed under extreme pressure during childbirth. For most women, hemorrhoids caused by pregnancy are a temporary problem.^[5]

Clinical Trials

Hemorrhoids Clinical Trials has a list of American goverment-sponsored clinical trials involving hemorrhoids.

Research

A drug that is being explored for a number of diseases of the digestive system works by disabling an enzyme in the body called Rho kinase. This enzyme helps control the anal sphincter, which maintains healthy bowel function. Overactivity of the enzyme may promote hemorrhoids. Research in rats has shown that administration of a Rho kinase inhibitor relaxes muscles in the anal sphincter. This approach is currently being investigated in the laboratory only. ^[6]

History

The medieval Jewish philosopher Moses Maimonides, who was also a physician, wrote about the origins, prevention and treatment of hemorrhoids in the 12th century C.E.^[7]

References

1. ↑ Vanscheidt W, Wolna P, Lücker PW et al. Efficacy and safety of a Butcher's broom preparation (Ruscus aculeatus L. extract) compared to placebo in patients suffering from chronic venous insufficiency. Arzneimittelforschung. 2002;52(4):243-50. Abstract
2. ↑ Memorial Sloan-Kettering Cancer Center: Butchers Broom.
3. ↑ Tan KY, Seow-Choen F. Fiber and colorectal diseases: separating fact from fiction. World J Gastroenterol. 2007 Aug 21;13(31):4161-7. Abstract | Full Text
4. ↑ Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology. 1990 Feb;98(2):380-6. Abstract
5. ↑ Staroselsky A, Nava-Ocampo AA, Vohra S, Koren G. Hemorrhoids in pregnancy. Can Fam Physician. 2008 Feb;54(2):189-90. Abstract | Full Text
6. ↑ Rattan S, De Godoy MA, Patel CA. Rho kinase as a novel molecular therapeutic target for hypertensive internal anal sphincter. Gastroenterology. 2006 Jul;131(1):108-16. Abstract | Press Release
7. ↑ Magrill D, Sekaran P. Maimonides: an early but accurate view on the treatment of haemorrhoids. Postgrad Med J. 2007 May;83(979):352-4. Abstract

External Links

Familydoctor.org: Fiber: How to Increase the Amount in Your Diet.