Haemorrhoids (US spelling “hemorrhoids” or “piles”) are not a disease. They are
a normal “plexus” or network of veins that surround the anal canal and lie under
the anal mucosa (the cell lining). Their name is derived from the Greek words
“haema” which means blood and “rhoe” which means flow.

Everybody has haemorrhoids. They are there for a reason: to help with
“continence” or control of your anal canal exit. They form a set of vascular
“cushions” which act in collaboration with the muscles of the anal sphincters and
help to seal the anus, preventing non-voluntary leak of wind or stools.

Although haemorrhoids are normal body structures, they cause a great number
of doctor’s appointments, investigations, treatments and operations. There are
two reasons for that.

The first reason is that haemorrhoids give some symptoms (rectal bleeding, pain,
irritation) that can also be caused by other, more serious anorectal conditions
such as cancer. So, patients may get worried and doctors need to confirm that
the only cause of the symptoms is the haemorrhoids and nothing more sinister.

It is important however to remember that haemorrhoids do not have any relation
to cancer and they do not cause cancer.

The second reason is that haemorrhoids can give rise to a number of symptoms,
which, although they are rarely serious, they can be quite annoying for the
suffering individual.

An important point to remember is that the cause of the symptoms of
haemorrhoids lies always higher up in the bowel. When the internal pressure
inside the abdomen and the lumen of the bowels rises above a certain level, then
the haemorrhoids come under strain and start giving symptoms. Exactly how high
the level of intra-abdominal pressure needs to be in order to cause symptoms is
not known and it probably varies according to the individual, the quality of their
tissues, the strength of the pelvic floor muscles etc.

The abdominal pressure can rise in a number of cases, either transiently or
chronically. An example of transient rise of the abdominal pressure is pregnancy.
It is well known that many pregnant women suffer from haemorrhoids because
the gradual growth of the uterus displaces the several organs and increases the
abdominal pressure.
Chronically elevated abdominal pressure is caused by obesity (accumulation of
fat inside the abdominal cavity), sedentary life style (people who do office work,
bus or taxi drivers and anyone who spends most of the day sitting), constipation
or chronic diarrhoea.
The definition of “constipation” is debatable and varies according to country and
culture. It is possible for people to open their bowels every day and still be
“constipated”. The term means that there is a degree of excessive straining that
has to occur with bowel movements every time. This straining results in excessive
contraction of abdominal and pelvic floor muscles and creates symptoms from
the haemorrhoids. Again, it is not possible to define exactly how severe the
straining has to be in order to produce symptoms from the haemorrhoids
because it varies from person to person. One thing is for certain: once
haemorrhoids start giving symptoms, the straining has exceeded the extent
tolerated by that person’s anal canal-haemorrhoids. Therefore efforts should be
directed towards relief of the strain.

SYMPTOMS

•        Prolapse
•        Rectal Bleeding
•        Anal Pain
•        Anal Irritation

Prolapse
Haemorrhoids prolapse as a result of straining and from internal they can
become external. The patient feels one or more lumps of the anal area that can
usually be pushed back in (third degree haemorrhoids) or they remain
permanently prolapsed (fourth degree haemorrhoids). Chronically prolapsing
external haemorrhoids can eventually be surrounded by skin and they are called
skin tags.
Prolapse causes concern for the patient because of the palpable lump, it can
also cause difficulties with local hygiene. In some cases prolapse that cannot be
reduced can be followed by thrombosis. This is a complication created by a blood
clot formed inside the haemorrhoid. The symptoms of thrombosis are sudden
severe pain associated with a very hard and tender lump which is of dark purple
colour. Treatment is either with emergency haemorrhoidectomy, or incision of the
haemorrhoid and removal of the clot. If the patient or the doctor have reasons to
avoid surgery then conservative management is possible with pain killers,
antibiotics and application of sugar and ice packs on the haemorrhoids. Sugar
works on the principle of osmosis: sugar molecules create an osmotic pressure
which draws the water from the swollen tissues and helps the swelling go down.

Rectal Bleeding
Bleeding from haemorrhoids is so common that has, at some point, been
experienced by most people. The blood that originates from the haemorrhoids
usually has the following features:
•        It is of bright red colour.
•        It is found more commonly on the toilet paper. However it can also be seen
dripping either in the beginning or in the end of the bowel movement. Sometimes
it can soil the underwear.
•        The bleeding is usually associated with straining, constipation or,
sometimes, exacerbation of diarrhoea (this also causes straining).
•        The amount of bleeding is usually limited, however in some cases patients
who bleed chronically can have anaemia.

As a rule of thumb, blood produced by haemorrhoids is not dark and not mixed
with the stools.

Anal Pain and Irritation
Anal Pain caused by haemorrhoids is usually described as discomfort, burning
sensation or irritation/ itching. There can be exacerbations, particularly after
straining on the toilet but presence of acute very severe pain usually implies a
different pathology: anal fissure. An exception to the rule is thrombosis of a
haemorrhoid which is described above.
Irritation or itching can be the result of external haemorrhoids which produce
mucous, poor local hygiene or the opposite: excessive zeal in frequent washing
of the area with strong soaps and antiseptics. Anxiety contributes to conscious or
unconscious (during sleep) scratching and prolongation of the irritation.

Diagnosis
This is easy on the grounds of the clinical history and symptoms. On examination
(rectal examination with the finger and proctoscopy) the haemorrhoids are
obvious. The main concern of the physician is to exclude the possibility of other
pathology of the rectum and colon which might give similar symptoms. The main
condition, that also causes rectal bleeding that needs to be excluded, is
colorectal cancer (see relevant chapter).

Treatment

1.        High Fibre Diet
As mentioned already, the presence of symptomatic haemorrhoids means that
there is a degree of constipation and straining even if the concerned individual is
not aware of it. There is plenty of evidence that a high content of fibre in the diet
accelerates the passage of the large bowel contents and results in decreased
pressures within the bowel. It is necessary however to accompany fibre with
water, approximately 30 mls for every kilogram of body weight per day. This for
most people is approximately 2 litres of water daily.
The recommended daily intake of fruits and vegetables is five portions daily.
Although  for most people this amount contains enough fibre to make their bowel
work normally, it is often desirable to further increase the fibre intake with fibre
supplements. This is either in the form of foods such as bran, muslin etc. or in
the form of medicinal supplements such as Fybogel etc.
High fibre diet,fibre supplements and high fluid intake will resolve the symptoms
of 90% of cases of haemorrhoids. In those cases no other action is necessary
and the patient should just adhere to this regime for life.

2.        Local medication
The symptoms of pain and irritation can be relieved by local application of a
variety of creams and suppositories which are widely available. Those
preparations are several combinations of local anaesthetic, soothing and anti-
inflammatory agents, and steroids. They are useful for control of the acute
exacerbation, however they cannot resolve the problem long term unless
combined with the diet measures explained above. Hot baths with one or two
spoonfuls of salt can provide relief during periods of severe pain and swelling.


3.        Lifestyle
As mentioned above, sedentary life predisposes to constipation. Research
studies have shown that exercise increases bowel motility and decreases
problems with constipation.

Interventional procedures
These are mainly sclerosing injections and rubber banding.
Sclerosing injections are, in my opinion, rather old – fashioned although still
widely practiced. They consist of sub-mucosal (under the cell lining and above
the haemorrhoids) injection of a “sclerosant” drug. This treatment is similar to the
sclerosing treatment of varicose veins. The principle is that the “sclerosant” drug
(usually oily phenol) causes a burn under the mucosa which subsequently heals
by developing scar tissue. This scar tissue acts as a thick covering layer over the
haemorrhoids, reducing the bleeding. Injections need to be repeated two or three
times over a period of 2-3 months for better results. The injection is done without
anaesthetic and is usually well tolerated. There is often a feeling of discomfort
and mild pain for 2-3 days afterwards which resolves spontaneously.
Injections are suitable only for internal haemorrhoids and the main symptom they
have an impact on is bleeding.
Disadvantages of injections are a) a high chance of recurrence of symptoms b)
complications. In rare occasions the sclerosant drug can accidentally escape the
sub-mucosal plane and can either go into the blood or into the prostate gland.
Severe burns can result in haemospermia (blood in the sperm) or prostatitis (a
painful inflammation of the prostate gland). If the sclerosant circulates in the
vessels it can cause thrombosis and inflammation and in rare occasions even
generalised sepsis and death have been described.


Rubber banding consists of “strangulating” the haemorrhoids with rubber bands
which are placed around them with the help of either a suction machine or a
specially designed band applicator. The procedure is done without an
anaesthetic and the patient may experience some mild pain for 2-3 days.
Approximately 2 weeks after the procedure there is an episode of noticeable
bleeding which corresponds to the falling off of the necrotic haemorroids. The
healing that follows, results in a thick scarry layer, preventing the haemorrhoids
from further bleeding.
Banding is also indicated for internal haemorrhoids only. As with injections there
is a risk of recurrence of the symptoms in the long term. Rare cases of sepsis
have also been described in the same way as with injections. A rare but
significant complication of banding is severe bleeding at the two weeks time point
which sometimes may require hospitalisation and transfusion.

Complications of injections and rubber banding are of course very rare but one
has to take into account that a trial that compared injections, banding and high
fibre diet concluded that they all had the same efficiency in relieving symptoms of
haemorrhoids. One therefore wonders whether it is worth taking any of the risk at
all since fibre alone is likely to be equally efficient.

Surgery: Haemorrhoidectomy

More than 90% of patients who complain about symptoms from haemorrhoids will
never require surgery. In the vast majority change of diet and lifestyle as well as
fibre supplements will improve greatly the condition. If the bleeding is the main
problem banding may be applied successfully.

However there are some patients who experience persistent symptoms from
haemorrhoids despite following the above advice. The bleeding may be too
frequent and become embarrassing or it can occasionally lead to anaemia. In
those cases surgery may be indicated.
Surgery should be reserved as the last solution and only if other measures have
failed.


1.   Excisional Haemorrhoidectomy (Milligan Morgan or diathermy
operation)

This is the traditional excision of haemorrhoids –usually with the electrical knife
(diathermy). It can be done as a day case. The wound is left open and takes 3-6
weeks to heal. Dressings are used only the first 3-4 days, after that daily salt
baths are only required. Pain killers and antibiotics as well as stool softeners are
given.

Excisional haemorrhoidectomy is an effective operation but its main disadvantage
is the great amount of post-operative pain. This is because the anus is a very
sensitive area and also prone to infection. The pain lasts for around 2 weeks and
the patient needs usually 2 weeks off work.

Complications are not very frequent but they do happen. Incontinence can be the
result of accidental damage of the sphincter, particularly in women who have had
previous sphincter damage during childbirth. In the case of very excessive
haemorrhoids we sometimes have to leave some of them behind. This is to avoid
the creation of a very extensive anal wound which will result in stricture of the
anus. Less serious complications include urine retention after surgery, prolonged
pain and early recurrence.

2. Stapled haemorrhoidectomy or Stapled Anopexy or PPH (Procedure for
Prolapse and Haemorrhoids)

This is a new operation that is now gaining ground in Europe and the USA as the
surgical treatment of choice for haemorrhoids.

A specially designed circular stapler knife (ETHICON) is used. The stapler cuts a
ring of anal mucosa with part of the haemorrhoids but the most important part is
the subsequent stapling of the anal canal which “lifts up” the prolapsing mucosa
(including the haemorrhoids). Over a period of a few weeks fibrotic scar develops
under the mucosa and prevents further prolapse and distention of haemorrhoids.

Several studies have shown that Stapled Haemorrhoidectomy has exactly the
same effectiveness as excisional haemorrhoidectomy but also one additional
great advantage: there is much less post-operative pain. This results in quicker
return of the patient to work and normal activities, usually 3 – 7 days.

Of course there is no procedure without complications and we have to mention
that in rare cases after stapled haemorrhoidectomy there can be a sensation of
urgency which some patients will find annoying. Similar complications as in
excisional haemorrhoidectomy can also occur, i.e. bleeding or sepsis.

Any operation has only 80% long term success rate. This means that if there is
no concurrent change in diet and lifestyle there is a 20% chance of recurrence
within 5 years.

At King's College Hospital our Department of Colorectal Surgery has extensive
experience with Stapled Haemorrhoidectomy and we organise and run the
"Stapled Haemorrhoidectomy Course" to teach surgeons from all over the UK
how to perform the procedure.

3. Ligasure Haemorrhoidectomy

Recently a new device has been introduced in the treatment of haemorrhoids.
This is the LigaSure™ Vessel Sealing System which fuses the vessels together
into forming a seal.
Ligasure has applications in all kinds of open and laparoscopic surgery and has
just been introduced with encouraging results in haemorrhoid surgery.
Ligasure haemorrhoidectomy needs to be studied in greater depth but there are
indications that it may replace diathermy haemorrhoidectomy.

Conclusion:

Haemorrhoids are a normal structure of the human anal canal which usually
suffers because of the wrong diet and lifestyle. In the majority of cases all
symptoms can be corrected with paying a little attention to those factors. When
symptoms become too severe banding can reduce the bleeding and Stapled
Haemorrhoidectomy (PPH) is emerging as the new procedure of choice for the
cases that require surgery.





©COPYRIGHT OF www.bowel-health.com contents by Dr. Savvas
Papagrigoriadis.  All rights reserved.
4th degree haemorrhoids
partially thrombosed
(courtesy of
www.proctosite.com)
The PPH stapler for
stapled
haemorrhoidectomy
(Ethicon Endosurgery)
Haemorrhoids
The  LigaSure™ Vessel
Sealing System