Haemorrhoids (piles)

Notes

## Basic Introduction

  • Haemorrhoids are dilated veins of the haemorrhoidal plexus (rectal venous plexus) in the anal canal.
  • Haemorrhoids are also defined as varicosities of haemorrhoidal plexus that is often complicated by inflammation, thrombosis, and bleeding.
  • They are classified into two categories: internal hemorrhoids and external hemorrhoids
  • Internal haemorrhoids are found above the dentate line (or pectinate line) while external haemorrhoids are found in the perianal skin just inside and outside the anal verge below the dentate line.
  • Occasionally, both internal and external hemorrhoids can co-exist

## Internal hemorrhoids

  • They are classified into Grade I – IV
  • Grade I or 1st degree hemorrhoids (grade I) do not prolapse
  • Grade II or 2nd degree haemorrhoids prolapse on straining but they reduce spontaneously
  • Grade III or 3rd degree haemorrhoids prolapse on straining and they can be reduced manually
  • Grade IV or 4th degree haemorrhoids are permanently prolapsed and they cannot be reduced manually.

## External hemorrhoids

  • They can be visible on external examination
  • They can also be painful and itchy as they have sensory innervation

## Statistics

  • Globally, the prevalence of haemorrhoids has been estimated at 4 - 34%
  • Globally, 50- 66% of the people will have haemorrhoid at one time in their lives.
  • Globally, the age that is most affected by haemorrhoids is 45-65 years old
  • The prevalence of haemorrhoids at Kenyatta National Hospital, Kenya, has been reported to be 21% for all ages and 29% among those who are ≥ 50 years (all of them being Grade I and mainly asymptomatic).

## Risk factors

  • Constipation
  • Sitting on the toilet for a long time
  • Diarrhea
  • Ascites
  • Pregnancy
  • Childbirth
  • Ageing
  • Chronic cough
  • Genetic factors
  • Heavy lifting

## Complications of treatment of haemorrhoids

  • Urinary retention
  • Hemorrhage
  • Abscess
  • Anal stricture
  • Constipation
  • Fissure
  • Incontinence
  • Pseudopolyp
  • Rectal perforation
  • Rectovaginal fistula
  • Sepsis
  • Skin tag
Symptoms
  • Mostly asymptomatic
  • Painless, bright red rectal bleeding when passing the stool (mainly internal hemorrhoids)
  • Pain and swelling in the anus (mainly external hemorrhoids)
  • A painful mass
  • Discomfort
  • Discharge
  • Pruritus
  • Prolapse of rectum
  • Soiling
  • Incontinence
Diagnosis
  • Clinical review
  • Digital rectal examination
  • Anoscopy, Colonoscopy or sigmoidoscopy may be necessary to rule out other diseases
Differential
  • Anal abscess
  • Carcinoma
  • Condyloma acuminata (anal warts)
  • Fissure
  • Fistula
  • Hypertrophied anal papilla
  • Melanoma
  • Perianal Crohn’s disease
  • Polyps
  • Rectal prolapse
Prevention
  • Increasing fiber intake and other measures to avoid constipation
  • Drinking fluids to maintain hydration
  • Improving anal hygiene
  • Avoiding diarrhea
  • Avoiding activities and practice that are likely to cause the diseases.
Reference
  1. Acheson AG, Scholefield JH; Management of haemorrhoids. BMJ. 2008 Feb 16;336 (7640):380-3
  2. Kaidar-Person, O; Person, B; Wexner, SD (January 2007). "Hemorrhoidal disease: A comprehensive review" . Journal of the American College of Surgeons. 204 (1): 102–17
  3. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf
  4. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf
  5. Ogendo SW. A study of haemorrhoids as seen at the Kenyatta National Hospital with special reference to asymptomatic haemorrhoids. East Afr Med J. 1991 May; 68 (5):340-7.
  6. Sun, Z; Migaly, J (March 2016). "Review of Hemorrhoid Disease: Presentation and Management.". Clinics in colon and rectal surgery. 29 (1): 22–9.
Management

## Lifestyle modifications

  • Increasing fiber intake and other measures to avoid constipation
  • Drinking fluids to maintain hydration
  • Improving anal hygiene
  • Avoiding diarrhea
  • Sitz baths - relieving anal pain and maintaining anal hygiene
  • Avoid prolonged sitting

## Oral medications

  • Oral vasotopic drugs such as purified flavonoid fraction-based tablets have proved to be useful in the management of haemorrhoids. It increases vascular tone, lymphatic drainage and capillary resistance, has anti-inflammatory effects as well as having wound healing promoting effect.

## Topical treatment

  • Topical application of corticosteroids may relieve the local perianal inflammation (in essence relieving pruritus and discomfort), but they should NOT be used for a long time as they are likely to cause permanent damage and thinning of the perianal skin.
  • Other topical preparations are astringent containing suppositories / ointment such as tribenoside/lignocaine, prednisolone/cinchocaine, and zinc oxide/bismuth oxide

## Sclerotherapy

  • This treatment is mainly reserved for patients with symptomatic non-prolapsing Grades I to II hemorrhoids.
  • The submucosa at the base of the hemorrhoid is injected with 5 mL of a preparation containing 5% phenol oil, vegetable oil, quinine, and urea hydrochloride or hypertonic salt solution.
  • This irritant sclerosant produces edema, an inflammatory reaction with the proliferation of fibroblasts, and intravascular thrombosis, creating submucosal fibrosis and scarring, which prevents the extent of the mucosal prolapse and reduces the hemorrhoidal tissue itself.

## Rubber-band ligation

  • This is the ligation of the hemorrhoidal tissue with a rubber band.
  • It causes ischemic necrosis, ulceration, and scarring, leading to fixation of the connective tissue to the rectal wall.
  • It is contraindicated in patients who are on anticoagulants.
  • This treatment is only for internal hemorrhoids

## Infrared coagulation

  • Infrared light penetrates the tissue and converts to heat leading to coagulation, occlusion, and sclerosis of the hemorrhoidal tissue

## Surgery

  • Thrombosed external hemorrhoids can resolve by itself but quicker relief is achieved by minor surgery (out-patient)
  • Ferguson’s (closed) hemorrhoidectomy
  • Milligan-Morgan (open) hemorrhoidectomy
  • Harmonic and LigaSure hemorrhoidectomy
  • Longo’s procedure (the procedure for prolapse and hemorrhoids)
  • Bipolar diathermy

## Other techniques

  • Bipolar diathermy
  • Anal Dilation (Lord’s Operation)
  • Direct-current electrotherapy
  • Cryotherapy
  • Laser therapy
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