Hemorrhoids – Anal Piles

Hemorrhoids, also known as piles, are abnormally enlarged /congested blood vessels in the anus. These are usually venous plexus, known as anal cushions. Though they are congested /enlarged veins, they are not simply varicosities. 10% of the general population will have hemorrhoids in their life.

The anal canal contains three anal cushions to provide efficient gas and fluid seal. Anal cushions are present in the submucosa of the anal canal, which are present in 3′, 7′, and 11′ o clock positions when the patient is in the lithotomy position. Anal cushions control stool by maintaining its consistency. Hemorrhoids are abnormal enlargements of anal cushions.

Hemorrhoids can be categorized as internal hemorrhoids and external hemorrhoids.

1. Internal hemorrhoids

Internal hemorrhoids usually appear above the dentate line, the level between the upper 1/3 and lower 2/3 part of the anal canal & the area which is supplied by autonomic fibers from the inferior hypogastric plexus. So internal hemorrhoids are usually painless unless there is any complication.

2. External hemorrhoids

External hemorrhoids are piles that appear near the anal verge due to swollen, congested blood vessels beneath the skin. External hemorrhoids are usually painful and could get complicated with thrombosed blood vessels.

Hemorrhoids Grading

1) 1st-degree hemorrhoids (grade 1) – Per rectal bleeding occurs, but the patient can not see or feel any lump

2) 2nd-degree hemorrhoids (grade2) – A lump prolapse out of the anus during defecation and return spontaneously up into the anal canal

3) 3rd-degree hemorrhoids (grade 3) – A lump prolapsed out of the anus during defecation, but it must replace manually.

4) 4th-degree hemorrhoids (grade 4) – The lump /pile can not be reduced because it has an external skin component.it stays out all the time

Hemorrhoids symptoms

Patients with hemorrhoids are usually asymptomatic. Some times patient may present with Rectal bleeding, Itching, and Prolapse.

1. The patient may present with a palpable lump or a sensation of something coming out of the anal verge in defecation. They will notice a swelling on wiping, which may spontaneously return or need to be manually pushed back.
2. Per rectal bleeding is another feature of hemorrhoids. Hemorrhoid bleeding presented as painless, bright red bleeding, which occurs during and after the defecation. Hemorrhoid bleeding may streak on feces, only noticed in toilet papers, or drip into the toilet. Sometimes the patient may experience copious bleeding after defecation, which makes the patient present with iron deficiency anemia.
3. Some patients may also present with perianal itching /pruritus due to mucus secretion from exposed mucosa on the perianal skin. This usually occurs with external hemorrhoids.

Causes for Hemorrhoids.

Mainly hemorrhoids develop,

1. When there is increased pressure in the lower rectum.
2. Resistance to venous drainage from the anal cushions.

So following causes will cause hemorrhoids.

1. Straining in bowel opening
2. Chronic constipation
3. Sitting for a long a period in the toilet
4. Heavy Lifting
5. low fiber diet

A low fiber diet, which decreases the bulk of the stool causing constipation and heavy staining, can increase the pressure on the lower rectum

On the other hand, when the pressure in the portal system and IVC increases, venous drainage from the anal cushion will reduce, causing hemorrhoids.

To understand this, we should know the venous drainage of the anal canal.

To understand this, we should know the venous drainage of the anal canal. Above the dentate line, the superior rectal vein drains into the portal vein through the inferior mesenteric vein. Below the dentate line, the inferior and middle rectal veins drain into IVC through the internal iliac vein. The venous plexus /anal cushion in the anal canal is formed by branches of these superior, middle and inferior rectal veins.

So in portal hypertension in a situation like cirrhosis and pressure on IVC in conditions like pregnancy and increased obesity, those patients can develop recurrent hemorrhoids until they get rid of the underlying condition.

Any factor that aggravates the causes mentioned above can increase the recurrence and severity of hemorrhoids.

Complications of hemorrhoids.

1. Anemia: hemorrhoids are usually asymptomatic. As it is usually painless, it is not usually detected. Some patients are only present with per rectal bleeding, which may be normally undetectable. Some patients present with copious bleeding after defecation. With prolonged bleeding or the copious bleeding patient may present with iron deficiency anemia. The patient also feels tired, weak, have shortness of breath, and has dizziness-like features.
2. Thrombosed prolapsed piles / thrombosed hemorrhoids: Thrombosed hemorrhoids are a really painful surgical emergency. Here submucosal blood vessels get thrombosed, so the pile becomes hard /edematous and tensed, making it painful on defecation.
3. Infection: Infections in hemorrhoids are rare but can occur if the patient is immunodeficient. If an infection occurs, it can be life-threatening.

Diagnosis, Examination, and Investigations

If a patient presented with a lump through the anal verge during defecation and per rectal bleeding, the doctor has to suspect hemorrhoids. Other than hemorrhoids, there are other differential diagnoses, such as perianal hematoma, rectal prolapse, anal prolapse, anal fissures, and carcinoma. To exclude these differential diagnoses following examinations are followed.

1. Digital rectal examination: At first, the doctor will examine the patient’s abdomen. Then will proceed to a Digital rectal examination. But piles, which are not prolapsed or thrombosed, can not be felt on digital rectal examination. The doctor can not confirm the diagnosis of hemorrhoids with only a Digital rectal examination.
2. Sigmoidoscopy: All patients with Rectal bleeding should be examined with sigmoidoscopy. This will help to see any other pathology lurking in the rectum.
3. Proctoscopy: Piles can be seen as darker in color with the proctoscopy. These piles bulge and protrude into the end of the proctoscope.

Hemorrhoid treatment and management.

Hemorrhoids can be treated and managed at home. If the symptoms don’t relieve and worsen, you have to look for a doctor, and doctors may go into more advanced treatment to manage this.
In managing hemorrhoids, we are usually using some conservative Hemorrhoid treatments.

1. The patient is advised to take a high fiber diet such as fruits like banana, papaya, mango, and vegetables and green leaves.
2. And reduce the intake of coffee and processed foods.
3. And drink sufficient water /fluid.
4. Sitz baths – The patient is asked to have baths by sitting in water where water is up to the hip.
5. If the patient has constipation, it should be treated with the Following drugs.
   • Bulk-forming laxatives such as Ispaghula husk (fybogel)- increase the bulk of the stool, which induces peristalsis. So the transit time of stool in the colon will reduce. So stool will easily pass out, and water retention from stool in the colon will reduce.
   • Lactulose-this increases the water content in the colon
   • Stool softeners(paraffin )
   • Stimulant laxatives(Bisacodyl/dulcolax)

If the patient is not resolved with these conservative treatments, other procedures are to carry out. Hemorrhoid treatment methods change according to hemorrhoid grading.

1. Sclerotherapy

Usually, for first-degree hemorrhoids, sclerotherapy is used. In sclerotherapy, about 2-3ml of 3% phenol in almond oil is injected above the pile. Here this solution is toxic to the endothelium. So the vein becomes sclerosed and collapses. We can use this technique for small second-degree piles as well.

As non-operative approaches, we can use rubber band ligation, cryosurgery, and photocoagulation.

2. Rubber band ligation

In rubber band ligation, an elastic band is applied to the hemorrhoids at the neck to cut its blood supply. Hemorrhoids will fall out in a few days. The band is placed above the dentate line without being too close to it. Otherwise, it will result in intense pain.

3. Cryosurgery

In cryosurgery, extreme cold is used to destroy the abnormal tissues.

4. Haemorrhoidectomy

Large second-degree and third-degree piles require haemorrhoidectomy, where hemorrhoids are surgically removed. There are several techniques used in haemorrhoidectomy.

1. Excisional haemorrhoidectomy

This is usually used in severe cases, especially In thrombosed external hemorrhoids. But this is associated with significant postoperative pain and takes some time to recover.

2. Stapled haemorrhoidectomy

Here enlarged haemorrhoidal tissues are removed. But not all. So the remaining hemorrhoidal tissues are repositioned back to their normal anatomical position. Compared to excisional haemorrhoidectomy, this is less painful and faster healing. But reappearing of symptomatic hemorrhoids is higher.

Hemorrhoidectomy complications include hemorrhage, acute urine retention, and stricture with anal stenosis if too much skin is excised.

Diet for Haemorrhoid patients

In hemorrhoids, foods to eat are fiber-containing foods. And also, they should be well hydrated. So they must drink water and fluids adequately.

Fibers are of two types.

1. Soluble fibers– They dissolve in water well. They make the stool soft, well-formed, and easy to pass. So no constipation.
2. Insoluble fiber They don’t dissolve in water. They help pass things through the bowels and balance the biochemical reactions in the intestines.

Many fibers contain foods that have both types.

Hemorrhoid patients should take 25-30 g or more fiber per day from what they eat. Not only that, they must drink more fluids, which helps the body to use fiber. Normally 8-10 large glasses should be drinking per day.

Best fiber-containing foods

1. Fruits and Vegetables

Apples, pears, plums, potatoes, berries, grapes, tomatoes, and kale.
Leafy greens, broccoli, Brussels sprouts, winter squash, and green peas. Cucumbers, celery, bell peppers, watermelon figs, apricots, and dates

2. Grains

Rye, oats, barley, and popcorn
Stone-ground cornmeal, buckwheat, and whole-grain flours

3. Beans, Lentils, and Nuts

navy, kidney, black, and lima beans

Foods not to eat

Eating lots of salt will drag water from the large intestine, leading to constipation. And also, iron supplements can cause constipation.
Foods that contain less amount of fiber can cause constipation. So better to avoid them. Foods like,

• Meat
• Processed foods such as fast food and frozen meals
• White bread 
• Dairy products