Hemorrhoid

Hemorrhoid or haemorrhoid (also commonly called piles) are vascular structures (similar to veins) in the anal canal which help with stool evacuation. We only speak of hemorrhoids (or piles) when they become swollen or inflamed. But Hemorrhoids are a normal part of the anatomy and everyone has these structures. They act as a cushion that is made of complex tissue. Their job is to aid the passage of stool. Hemorrhoids are very common. Nearly three out of four adults will have hemorrhoids from time to time.^[1]

It is not known what causes hemorrhoids, but doctors often speak of several main factors.^[2] These factors include chronic constipation or diarrhea, sitting on the toilet for a long time and straining during defecation. Hemorrhoids may also appear because of sports. When something heavy is lifted, additional pressure is applied on the area. Women are in danger of having hemorrhoids during pregnancy. This also happens due to increased pressure from the baby. Hemorrhoids are more likely with aging because the tissue becomes weaker.^[1] Some people are more likely to get hemorrhoids if other family members have them. Receptive partners in anal intercourse are also in risk of heorrhoids.^[3][4][5]

According to their anatomical origin hemorrhoids can be two types - internal and external. Internal hemorrhoids originate from inside the anus. But internal hemorrhoids can also go down and show outside the anus. In this case, medical professionals are talking about prolapse.^[6]

Symptoms of internal hemorrhoids include itching, bleeding, swelling, mucus discharge, burning sensation, prolapse, and soiling. Patients also complain of general discomfort while sitting, feeling of fullness and presence of a foreign body inside the anus.^[7] Internal hemorrhoids can only cause painless bleeding from the anus, while external hemorrhoids are painful. External hemorrhoids are located on the outside of the anus. They look like a bluish lump. But sometimes internal hemorrhoids can also become extremely painful. This happens because they develop a clot. In these cases, a thrombosed hemorrhoid occurs and it may have to be operated. Pain in the area around the anus may be due to another disease, such as anal fissure, anal fistula, or proctitis.^[8]

Hemorrhoids are diagnosed by a doctor. A visual examination of the anus is usually needed. The doctor may want to perform a rectal examination which will help detect internal hemorrhoids, tumours, polyps, or abscesses.^[8] The visual examination usually requires a special device, called anoscope to be inserted in the anus. The procedure is painless unless another disease is presented.

Treatment of hemorrhoids can be done at home or in the hospital. Usually, the best option is to prevent getting them. This can be done by keeping the stools soft and bulk, so they pass easily during defecation. Stools can be made softer and larger by increasing fiber intake.^[9] This means eating more fruits, vegetables, and whole grains. Most people do not have enough fiber in their diet. In such case, fiber supplements, such as psyllium or methylcellulose, can be of benefit.^[10] As being receptive partner in anal sex is also a way of risk to get hemorrhoids, one should be careful of being receptive partner during anal sex, and he can be mostly safe from getting hemorrhoids through anal sex by totally avoiding it.^[11]

It is also important to increase fluids intake and maintain hydration. It is recommended to drink six to eight glasses of water a day to help keep stools soft.^[1]

Home treatment may include sitz baths, topical creams, and suppositories. There are many types available for the treatment of hemorrhoids, but there is little evidence supporting their use.^[12]

Diosmin-Hesperidin compound is the most commonly used flavonoids for the primary treatment for hemorrhoids, which is present in citrus fruit's peel extract. It is sold in the United States and other countries in the brand name of Daflon and Venalex in tablet form, but studies have questioned it's benefits and, according to researchers, are likely to cause side effects.

Small lifestyle modifications are important when dealing with hemorrhoids. Not straining during defecation and going as soon as the urge appears are important measures. Staying active can help prevent constipation and reduce weight.^[10]

Sometimes hemorrhoids can not be treated at home or the patient seeks help. Doctors can treat hemorrhoids with office procedures or in a hospital setting.

Office treatments include:

• Rubber band ligation - Rubber band ligation is a simple procedure. The doctor uses a special device to place a rubber band around the hemorrhoid. The band cuts off the blood supply to the hemorrhoid. The hemorrhoid will then fall within a week. Scar tissue then forms to keep the remaining tissue fixated.^[13] This procedure is usually painless, because there are no nerve endings where the rubber band is placed. The patient should seek medical assistance if extreme pain is felt. This might be due to thrombosis.
• Sclerotherapy - the procedures involves an injection into the internal hemorrhoid. The injection contains special solution which causes scar tissue to form and shrink the hemorrhoid.^[14]
• Infrared photocoagulation - In this procedure infrared light is applied at the internal hemorrhoid. The infrared light causes scar tissue to form, which cuts off the blood supply and shrinks the hemorrhoid.^[14]
• Electrocoagulation. A special device is used to apply electric current onto the internal hemorrhoid. The procedure causes scar tissue to form, which cuts off the blood supply and shrinks the hemorrhoid.^[14]

In severe cases when home and office procedures fail, a surgical approach can be considered. There are several surgical techniques used. All of them are associated with different complications, such as bleeding, infection (sepsis), anal strictures, fecal incontinence, etc.^[15] Some of the procedures involve hemorrhoid removal. These procedures are commonly known as Hemorrhoidectomy. There are several variants, but in all of them, the surgeon will remove the hemorrhoids. The procedure can be performed to remove external and large prolapsing internal hemorrhoids. Hemorrhoidectomy is infamous for being very painful.^[16] This is due to specific location, where the procedure is performed. The anal canal contains many nerves, which can easily be traumatized.

Other surgical procedures include - stapled hemorrhoidopexy (PPH, Longo's procedure) and doppler-guided artery ligation (DG-HAL/RAR or THD).

Stapled hemorrhoidopexy involves a special device, called stapler, which lifts and fixates the prolapsed hemorrhoids.^[17] The stapler will also excise mucosal tissue to block the blood flow to the remaining hemorrhoids. However, stapling procedure is associated with a greater risk of recurrence.^[15]

Doppler-guided ligation of hemorrhoidal arteries (DG-HAL/RAR or THD) has been recently purposed as a safe and relatively painless alternative to hemorrhoidectomy.^[18] A special ultrasound device is applied to identify the arteries that supply the hemorrhoids. The surgeon will then will the ligate them, cutting the blood supply and preventing further problems. However, the procedure is associated with a high recurrence rate.^[19]

• Hemorrhoidolysis, a treatment for hemorrhoids

1. ↑ ^{1.0 1.1 1.2} "Hemorrhoids - Symptoms and causes". Mayo Clinic. Retrieved 2017-08-11.
2. ↑ von Roon, Alexander C.; Reese, George E.; Tekkis, Paris P. (2009-01-29). "Haemorrhoids: haemorrhoidal artery ligation". BMJ Clinical Evidence. 2009. ISSN 1752-8526. PMC 2907769. PMID 19445775.
3. ↑ Fitzgerald, Margaret A. (4 December 2020). Nurse Practitioner Certification Exam Prep. F.A. Davis. ISBN 978-1-7196-4298-9. Retrieved 6 July 2023.
4. ↑ Ferri, Fred F. (1 June 2019). Ferri's Clinical Advisor 2020 E-Book: Ferri's Clinical Advisor 2020 E-Book. Elsevier Health Sciences. ISBN 978-0-323-67977-0. Retrieved 6 July 2023.
5. ↑ Bernstein, Melissa; Luggen, Ann Schmidt (28 January 2011). Nutrition for the Older Adult. Jones & Bartlett Publishers. p. 116. ISBN 978-1-4496-6396-4. Retrieved 6 July 2023.
6. ↑ "What Are Hemorrhoids?". WebMD. Retrieved 2017-08-11.
7. ↑ "Proktos.info | Symptoms and diagnosis". Proktos.info. Retrieved 2017-08-11.^{[permanent dead link]}
8. ↑ ^{8.0 8.1} Pfenninger, John L.; Zainea, George G. (2001-06-15). "Common Anorectal Conditions: Part I. Symptoms and Complaints". American Family Physician. 63 (12): 2391–2398. ISSN 0002-838X. PMID 11430454.
9. ↑ "Fiber and Digestion Problems". WebMD. Retrieved 2017-08-11.
10. ↑ ^{10.0 10.1} "Treatment of Hemorrhoids | NIDDK". National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved 2017-08-11.
11. ↑ PDxMD Gastroenterology. Elsevier - Health Sciences Division. 2002. ISBN 978-1-932141-04-7. Retrieved 9 December 2023.
12. ↑ Lohsiriwat, Varut (2015-08-21). "Treatment of hemorrhoids: A coloproctologist's view". World Journal of Gastroenterology : WJG. 21 (31): 9245–9252. doi:10.3748/wjg.v21.i31.9245. ISSN 1007-9327. PMC 4541377. PMID 26309351.
13. ↑ "Rubber Band Ligation for Hemorrhoids". WebMD. Retrieved 2017-08-11.
14. ↑ ^{14.0 14.1 14.2} Song, Seok-Gyu; Kim, Soung-Ho (December 2011). "Optimal Treatment of Symptomatic Hemorrhoids". Journal of the Korean Society of Coloproctology. 27 (6): 277–281. doi:10.3393/jksc.2011.27.6.277. ISSN 2093-7822. PMC 3259422. PMID 22259741.
15. ↑ ^{15.0 15.1} "Hemorrhoids - Diagnosis and treatment". Mayo Clinic. Retrieved 2017-08-11.
16. ↑ Medina-Gallardo, Adrian; Curbelo-Peña, Yuhamy; De Castro, Xavier; Roura-Poch, Pere; Roca-Closa, Josep; De Caralt-Mestres, Enric (2016-11-15). "Is the severe pain after Milligan-Morgan hemorrhoidectomy still currently remaining a major postoperative problem despite being one of the oldest surgical techniques described? A case series of 117 consecutive patients". International Journal of Surgery Case Reports. 30: 73–75. doi:10.1016/j.ijscr.2016.11.018. ISSN 2210-2612. PMC 5153430. PMID 27960130.
17. ↑ "Proktos.info | Stapled Hemorrhoidopexy (PPH)". Proktos.info. Retrieved 2017-08-11.^{[permanent dead link]}
18. ↑ Ratto, C.; de Parades, V. (2015-04-01). "Doppler-guided ligation of hemorrhoidal arteries with mucopexy: A technique for the future". Journal of Visceral Surgery. 152/2S "Proctology". 152 (2): S15–S21. doi:10.1016/j.jviscsurg.2014.08.003. PMID 25262549.
19. ↑ Liu, Hong; Yang, Chunmei; Chen, Benhui; Wu, Jing; He, Hongbo (2015-04-15). "Clinical outcomes of Doppler-guided haemorrhoidal artery ligation: a meta-analysis". International Journal of Clinical and Experimental Medicine. 8 (4): 4932–4939. ISSN 1940-5901. PMC 4483950. PMID 26131066.