Hemorrhoids

(Piles, Rectal Swelling)

The Facts

Hemorrhoids, also called "piles," are swollen tissues that contain veins. They are located in the wall of the rectum and anus and may cause minor bleeding or develop small blood clots. Hemorrhoids occur when the tissues enlarge, weaken, and come free of their supporting structure. This results in a sac-like bulge that extends into the anal area.

Hemorrhoids are unique to humans – no other animal develops them. They are very common – up to 86% of people will report they have had hemorrhoids at some time in their life, though people often use this as a catch-all label for any ano-rectal problem including itching. They can occur at any age but are more common between the ages of 45 and 65. Among younger people, they are most common in people who are pregnant.

Although they can be embarrassing to talk about, anyone can get hemorrhoids, even healthy young people in good shape. They can be painful and annoying but aren't usually serious. Hemorrhoids differ depending on their location and the amount of pain, discomfort, or aggravation they cause.

Internal hemorrhoids are located up inside the rectum. They rarely cause any pain, as this tissue doesn't have any sensory nerves. These hemorrhoids are graded for severity according to how far and how often they protrude into the anal passage or protrude out of the anus (prolapse):

Grade I is small without protrusion. Painless, minor bleeding occurs from time to time after a bowel movement.
A grade II hemorrhoid may protrude during a bowel movement but returns spontaneously to its place afterwards.
In grade III, the hemorrhoid must be put back in place manually.
A grade IV hemorrhoid has prolapsed – it protrudes constantly and will fall out again if pushed back into the rectum. There may or may not be bleeding. Prolapsed hemorrhoids can be painful.

External hemorrhoids develop under the skin just inside the opening of the anus. The hemorrhoids may swell and the area around it may become firm and sore, turning blue or purple in colour when they get thrombosed. A thrombosed hemorrhoid is one that has formed a clot inside. This clot is not dangerous and will not spread through the body, but does cause pain and should be drained. External hemorrhoids may itch and can be very painful, especially during a bowel movement. They can also prolapse.

The Causes

Hemorrhoids are caused by repeated or constant pressure on the rectal or anal veins. The most common cause of pressure usually results from straining or prolonged sitting during a bowel movement. Other factors that increase the risk for getting hemorrhoids include constipation, diarrhea, lifting heavy objects, poor posture, prolonged sitting or standing, pregnancy, and being overweight. Liver damage and some food allergies can also add stress to the rectal veins.

Symptoms And Complications

External hemorrhoids most often itch, burn, or bleed, and they can be painful and swollen. They're the most common cause of bleeding during bowel movements.

A small, painless emission of very bright red blood in the stool or on the toilet paper just after a bowel movement is a sign of an internal hemorrhoid. The blood will be on the surface of the stool only, not mixed in. In small amounts, it's not a serious issue. If this is the first occurrence, see your doctor to confirm that hemorrhoids are the source. Visit your doctor if bleeding continues, as a constant loss of blood may lead to anemia (a condition where there are not enough red blood cells to bring oxygen to your tissues).

Watch for pain that lasts longer than a week, blood loss along with weakness or dizziness, or if the hemorrhoid does not go back in place after a bowel movement – these are all situations that should be brought to your doctor's attention. Your doctor should also be consulted about bleeding not brought on by a bowel movement, blood that's dark in colour, or bleeding that is recurrent. This can signal more serious problems higher in the colon, unrelated to hemorrhoids.

Also, children under 12 should be referred to a doctor if symptoms of hemorrhoids are present.

Making A Diagnosis

No examination for hemorrhoids is complete without a digital rectal examination, where the doctor will insert a gloved finger into the rectum to examine the hemorrhoids. This helps to determine if the hemorrhoid is external or internal, and to assess the grade of internal hemorrhoids. Blood does not usually need to be drawn.

An instrument called an anoscope or a proctoscope lets the doctor see internal hemorrhoids. The examination should also include questions about lifestyle. The doctor will probably try to isolate risk factors and suggest changes.

Be sure to tell your doctor the following:

your health history and any family history of hemorrhoids or intestinal disease
your medication history, especially if it includes any medications that affect blood clotting(e.g., clopidogrel, warfarin)*

Treatment And Prevention

A high-fibre diet with large amounts of water is the answer for grade I internal hemorrhoids and painless external hemorrhoids. This will soften the stool, decreasing constipation and straining. It will also allow the inflamed veins to decrease in size. There are also a number of creams, ointments, suppositories, and wipes available without prescription that can help reduce pain and inflammation around the anus. Some of these include topical hemorrhoidal preparations applied to the affected area that contain local anesthetics with soothing properties. Your pharmacist can help you choose a preparation that is appropriate for your circumstances. Prescription medications can include anti-inflammatory cortisone creams.

Other useful measures include stool softeners or bulking agents to help prevent constipation. A sitz bath, used 3 or 4 times daily for 15 minutes at a time, can help to soothe symptoms. A sitz bath is a container filled with warm water that fits over a toilet bowl. Ice packs alternated with warm packs on the affected area can help dissolve a blood clot in an external hemorrhoid.

Pain relievers such as acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) can be used to alleviate the pain of an external hemorrhoid.

More severe hemorrhoids may require a doctor's intervention. External hemorrhoids can be removed or drained with local anaesthetic and a scalpel by a doctor if they have developed a clot within the previous 72 hours.

Internal hemorrhoids, depending on the hemorrhoid grade, may require procedures that can either be done in the doctor’s office or require an operation. Sometimes, a hardening agent is injected into internal hemorrhoids to make them smaller and firmer. Grade I through III internal hemorrhoids may be tied off with a rubber band via rubber band ligation. This stops the blood flow and the hemorrhoids eventually die and drop off within 5 to 7 days. Electricity, lasers, heat, cold, or infrared light are also used to destroy hemorrhoids. These procedures can involve some discomfort.

A hemorrhoidectomy is a type of surgery done under anesthesia. It involves complete removal of internal hemorrhoids. It's reserved for severe cases where other treatments have failed or can't be tolerated. Hemorrhoidectomy has the lowest rate of recurrence (hemorrhoids coming back) but has the highest rate of post-surgery pain.

Here are a few tips on preventing hemorrhoids:

Don't delay bowel movements, because the stool can harden.
Avoid straining to have a bowel movement, and don't stay sitting on the toilet for long periods (over 5 minutes at a time).
Drink 6 to 8 glasses of water a day.
Eat foods that are high in fibre and bulk, such as whole-grain foods, fresh vegetables, and fruit – especially prunes and bran.
Get plenty of exercise and don't sit for prolonged periods of time. Try to go for walks.
Lose excess weight.