What are the different types of hemorrhoids. How can you identify hemorrhoids without bleeding. What causes hemorrhoids to develop. Which treatments are most effective for hemorrhoids. When should you seek medical attention for hemorrhoids. How can you prevent hemorrhoids from recurring.

Understanding Hemorrhoids: More Than Just Bleeding

Hemorrhoids, often referred to as piles, are a common medical condition affecting millions worldwide. While bleeding is a well-known symptom, it’s crucial to understand that hemorrhoids can exist without this telltale sign. These swollen veins in the lower rectum and anus can cause discomfort and various other symptoms, even when no visible bleeding occurs.

To answer the question directly: Yes, you can have hemorrhoids without bleeding. In fact, many individuals experience hemorrhoids with symptoms such as itching, pain, or a feeling of fullness in the rectal area, all without any noticeable blood. Understanding the full spectrum of hemorrhoid symptoms is essential for early detection and proper treatment.

The Silent Symptoms of Hemorrhoids

When hemorrhoids develop without bleeding, they may manifest through other signs:

• A feeling of fullness or pressure in the rectal area
• Itching or irritation around the anus
• Pain or discomfort during bowel movements
• A visible or palpable lump near the anal opening
• Difficulty cleaning the area after a bowel movement

These symptoms can vary in intensity and may come and go over time. It’s important to note that the absence of bleeding doesn’t necessarily indicate a less severe condition. In some cases, non-bleeding hemorrhoids can still cause significant discomfort and require medical attention.

Types of Hemorrhoids: Internal vs. External

Understanding the different types of hemorrhoids is crucial for proper diagnosis and treatment. There are two main categories: internal and external hemorrhoids. Each type has its unique characteristics and potential symptoms.

Internal Hemorrhoids: The Hidden Culprits

Internal hemorrhoids develop inside the rectum and are often painless due to the lack of pain-sensing nerves in this area. These hemorrhoids can exist without causing any noticeable symptoms, making them challenging to detect without a medical examination. However, they may occasionally prolapse (protrude outside the anus) during bowel movements, leading to discomfort or irritation.

Symptoms of internal hemorrhoids may include:

• Painless bleeding during bowel movements
• Prolapse or tissue protrusion during or after bowel movements
• Mucus discharge
• A feeling of incomplete evacuation after a bowel movement

External Hemorrhoids: The Visible Offenders

External hemorrhoids form under the skin around the anus and are more likely to cause noticeable symptoms due to the abundance of pain-sensing nerves in this area. These hemorrhoids are often visible and can be felt as small, firm lumps.

Common symptoms of external hemorrhoids include:

• Pain or discomfort, especially when sitting
• Itching or irritation in the anal area
• Swelling around the anus
• Bleeding, particularly if a blood clot forms (thrombosed hemorrhoid)

Is it possible to have both internal and external hemorrhoids simultaneously? Indeed, some individuals may experience a combination of both types, leading to a more complex set of symptoms and potentially requiring a multi-faceted treatment approach.

The Root Causes of Hemorrhoids: Understanding the Risk Factors

Hemorrhoids develop when there’s increased pressure in the lower rectum, causing the veins to swell and stretch. While the exact cause can vary from person to person, several factors contribute to their formation.

Lifestyle Factors Contributing to Hemorrhoid Development

Many everyday habits and choices can increase the risk of developing hemorrhoids:

• Prolonged sitting or standing
• Lack of physical activity
• Low-fiber diet
• Chronic constipation or diarrhea
• Straining during bowel movements
• Obesity
• Pregnancy and childbirth

Do certain professions increase the risk of hemorrhoids? Occupations that involve prolonged sitting or standing, such as truck drivers, office workers, or retail employees, may indeed have a higher likelihood of developing hemorrhoids. Taking regular breaks to move around or change positions can help mitigate this risk.

Medical Conditions Associated with Hemorrhoids

Some health issues can contribute to the development or exacerbation of hemorrhoids:

• Chronic liver disease
• Portal hypertension
• Inflammatory bowel diseases (e.g., Crohn’s disease, ulcerative colitis)
• Rectal or colon cancer

Is there a genetic component to hemorrhoid development? While hemorrhoids themselves are not directly inherited, the tendency to develop them may run in families. This could be due to shared lifestyle factors or inherited traits that affect vein elasticity or bowel function.

Diagnosis: Identifying Hemorrhoids Without Bleeding

Diagnosing hemorrhoids, especially when they don’t bleed, requires a careful medical evaluation. Healthcare providers use various methods to identify and assess the severity of hemorrhoids.

Physical Examination Techniques

The initial step in diagnosing hemorrhoids typically involves a physical examination. This may include:

• Visual inspection of the anal area
• Digital rectal examination
• Anoscopy (examination of the anal canal and lower rectum with a small, lighted instrument)

During these examinations, the doctor looks for signs of swelling, lumps, or irritation that might indicate the presence of hemorrhoids, even in the absence of bleeding.

Advanced Diagnostic Procedures

In some cases, especially when internal hemorrhoids are suspected or other conditions need to be ruled out, more advanced diagnostic procedures may be necessary:

• Sigmoidoscopy: Examination of the lower part of the colon
• Colonoscopy: Inspection of the entire colon
• Imaging tests: Such as endoanal ultrasound or MRI, in complex cases

How can you differentiate between hemorrhoids and other anal conditions? While hemorrhoids share symptoms with conditions like anal fissures or rectal prolapse, a thorough medical examination can usually distinguish between these issues. The location, appearance, and associated symptoms often provide clues to the correct diagnosis.

Effective Treatments for Non-Bleeding Hemorrhoids

Even when hemorrhoids don’t bleed, they can cause significant discomfort and require treatment. The approach to treatment often depends on the severity of symptoms and the type of hemorrhoids present.

Home Remedies and Lifestyle Changes

For mild cases, conservative treatments and lifestyle modifications can often provide relief:

• Increasing fiber intake through diet or supplements
• Staying hydrated to soften stools
• Avoiding straining during bowel movements
• Using over-the-counter creams or ointments for symptom relief
• Taking warm sitz baths to soothe the area
• Applying cold compresses to reduce swelling

How long should you try home remedies before seeking medical treatment? While mild hemorrhoids often respond to home care within a week or two, persistent symptoms or worsening discomfort warrant a consultation with a healthcare provider.

Medical and Surgical Interventions

When home remedies aren’t sufficient, medical treatments may be necessary:

• Rubber band ligation: Placing a small elastic band around the base of an internal hemorrhoid to cut off its blood supply
• Sclerotherapy: Injecting a chemical solution to shrink the hemorrhoid
• Infrared coagulation: Using infrared light to create scar tissue that cuts off the blood supply to the hemorrhoid
• Hemorrhoidectomy: Surgical removal of large or severe hemorrhoids
• Stapled hemorrhoidopexy: A procedure that pulls prolapsed tissue back into place and staples it there

Are there any new or experimental treatments for hemorrhoids? Emerging treatments include radiofrequency ablation and laser therapy, which aim to reduce hemorrhoid size and symptoms with minimal invasiveness. However, these methods are still being studied for long-term efficacy and safety.

Prevention Strategies: Keeping Hemorrhoids at Bay

While not all cases of hemorrhoids can be prevented, adopting certain lifestyle habits can significantly reduce the risk of developing them or experiencing recurrences.

Dietary Adjustments for Hemorrhoid Prevention

A diet rich in fiber and proper hydration plays a crucial role in preventing hemorrhoids:

• Increase intake of fruits, vegetables, and whole grains
• Consider fiber supplements if dietary changes aren’t sufficient
• Drink plenty of water throughout the day
• Limit consumption of processed foods and excessive red meat

How much fiber is needed daily to help prevent hemorrhoids? The recommended daily fiber intake is about 25-30 grams for adults. Gradually increasing fiber intake and staying well-hydrated can help prevent constipation and reduce strain during bowel movements.

Lifestyle Modifications for Long-Term Prevention

Beyond diet, several lifestyle changes can contribute to hemorrhoid prevention:

• Regular exercise to improve circulation and bowel function
• Avoiding prolonged sitting or standing
• Practicing good bathroom habits (e.g., not straining, limiting time on the toilet)
• Maintaining a healthy weight
• Addressing chronic constipation or diarrhea promptly

Can certain exercises help prevent hemorrhoids? Yes, exercises that improve circulation and strengthen the pelvic floor muscles, such as Kegel exercises and regular walking, can help prevent hemorrhoids. However, avoid heavy lifting or straining exercises that might increase intra-abdominal pressure.

When to Seek Medical Attention: Red Flags and Complications

While many cases of hemorrhoids can be managed at home, certain symptoms or complications require prompt medical evaluation.

Warning Signs That Require Immediate Attention

Seek medical care if you experience any of the following:

• Severe pain or swelling in the anal area
• Persistent bleeding or blood clots
• Signs of infection, such as fever or pus discharge
• Hemorrhoids that don’t improve with home treatment after a week
• Anemia symptoms (fatigue, weakness, shortness of breath) due to blood loss

Can hemorrhoids lead to more serious complications if left untreated? While rare, untreated hemorrhoids can potentially lead to complications such as strangulation (where the blood supply to the hemorrhoid is cut off), severe anemia from chronic bleeding, or infection. Prompt treatment can prevent these more serious issues.

Differential Diagnosis: When It Might Not Be Hemorrhoids

Sometimes, symptoms attributed to hemorrhoids may be signs of other conditions:

• Anal fissures
• Rectal prolapse
• Inflammatory bowel disease
• Colorectal cancer
• Anal or rectal abscesses

How can you distinguish between hemorrhoid symptoms and those of more serious conditions? While only a medical professional can provide a definitive diagnosis, persistent or worsening symptoms, unexplained weight loss, changes in bowel habits, or blood mixed with stool (rather than just on the surface) may indicate a need for further investigation beyond hemorrhoids.

In conclusion, hemorrhoids, whether bleeding or non-bleeding, are a common and often manageable condition. By understanding the types, causes, and available treatments, individuals can take proactive steps to prevent their occurrence and seek appropriate care when needed. Remember, while many cases can be addressed with home remedies and lifestyle changes, persistent or severe symptoms should always be evaluated by a healthcare professional to ensure proper diagnosis and treatment.

Hemorrhoids (Internal & External): Pictures, Symptoms, Causes, Treatment

What Are Hemorrhoids?

Hemorrhoids are swollen veins in the lowest part of your rectum and anus. Sometimes, the walls of these blood vessels stretch so thin that the veins bulge and get irritated, especially when you poop. Hemorrhoids are also called piles.

Hemorrhoids are one of the most common causes of rectal bleeding. They often go away on their own. Treatments can also help.

Symptoms of Hemorrhoids

Internal hemorrhoids

Internal hemorrhoids are so far inside your rectum that you can’t usually see or feel them. They don’t generally hurt because you have few pain-sensing nerves there. Symptoms of internal hemorrhoids include:

• Blood on your poop, on toilet paper after you wipe, or in the toilet bowl
• Tissue that bulges outside your anal opening (prolapse). This may hurt, often when you poop. You might be able to see prolapsed hemorrhoids as moist bumps that are pinker than the surrounding area. These usually go back inside on their own. Even if they don’t, they can often be gently pushed back into place.

External hemorrhoids

External hemorrhoids are under the skin around your anus, where there are many more pain-sensing nerves. Symptoms of external hemorrhoids include:

Thrombosed hemorrhoids

A blood clot can turn an external hemorrhoid purple or blue. This is called a thrombosis or a thrombosed hemorrhoid. You may notice symptoms like:

• Severe pain
• Itching
• Bleeding

When to call your doctor

Hemorrhoids are rarely dangerous. If the symptoms don’t go away in a week or if you have bleeding, see your doctor to make sure you don’t have a more serious condition.

Causes and Risk Factors of Hemorrhoids

You may be more likely to get hemorrhoids if other family members, like your parents, had them.

Pressure building up in your lower rectum can affect blood flow and make the veins there swell. That may happen from:

• Pushing during bowel movements
• Straining when you do something that’s physically hard, like lifting something heavy
• Extra weight, like obesity
• Pregnancy, when your growing uterus presses on your veins
• A diet low in fiber
• Anal sex

People who stand or sit for long stretches of time are at greater risk, too.

You may get them when you have constipation or diarrhea that doesn’t clear up. Coughing, sneezing, and vomiting could make them worse.

Hemorrhoids Diagnosis

Your doctor will ask about your medical history and symptoms. They’ll probably need to do one or both of these examinations:

• Physical exam. Your doctor will look at your anus and rectum to check for lumps, swelling, irritation, or other problems.
• Digital rectal exam. Your doctor will put on gloves, apply lubrication, and insert a finger into your rectum to check muscle tone and feel for tenderness, lumps, or other problems.

To diagnose internal hemorrhoids or rule out other conditions, you might need a more thorough test, including:

• Anoscopy. Your doctor uses a short plastic tube called an anoscope to look into your anal canal.
• Sigmoidoscopy. Your doctor looks into your lower colon with a flexible lighted tube called a sigmoidoscope. They can also use the tube to take a bit of tissue for tests.
• Colonoscopy. Your doctor looks at all of your large intestine with a long, flexible tube called a colonoscope. They can also take tissue samples or treat other problems they find.

Hemorrhoids Treatment

Hemorrhoid symptoms usually go away on their own. Your doctor’s treatment plan will depend on how severe your symptoms are.

• Home remedies. Simple lifestyle changes can often relieve mild hemorrhoid symptoms within 2 to 7 days. Add fiber to your diet with over-the counter supplements and foods like fruit, vegetables, and grains. Try not to strain during bowel movements; drinking more water can make it easier to go. Warm sitz baths for 20 minutes several times a day may also make you feel better. Ice packs can ease pain and swelling.
• Nonsurgical treatments. Over-the-counter creams and other medications ease pain, swelling, and itching.
• Surgical treatments. If you have large hemorrhoids, or if other treatments haven’t helped, you might need surgery. Your doctor can use chemicals, lasers, infrared light, or tiny rubber bands to get rid of them. If they’re especially large or keep coming back, your doctor might need to remove them with a sharp tool called a scalpel.

Hemorrhoids Complications

Rarely, hemorrhoids could lead to problems such as:

• Skin tags. When the clot in a thrombosed hemorrhoid dissolves, you may have a bit of skin left over, which could get irritated.
• Anemia. You might lose too much blood if you have a hemorrhoid that lasts a long time and bleeds a lot.
• Infection. Some external hemorrhoids have sores that get infected.
• Strangulated hemorrhoid. Muscles can block the blood flow to a prolapsed hemorrhoid. This may be very painful and need surgery.

Hemorrhoids Prevention

To prevent hemorrhoid flare-ups, try these steps:

• Eat fiber. It helps food pass through your system easier. A good way to get it is from plant foods: vegetables, fruits, whole grains, nuts, seeds, beans, and legumes. Aim for 20 to 35 grams of dietary fiber a day.
• Use fiber supplements. Over-the-counter supplements can help soften stool if you don’t get enough fiber from food. Start with a small amount, and slowly use more.
• Drink water. It will help you avoid hard stools and constipation, so you strain less during bowel movements. Fruits and vegetables, which have fiber, also have water in them.
• Exercise.  Physical activity, like walking a half-hour every day, keeps your blood and your bowels moving.
• Don’t wait to go. Use the toilet as soon as you feel the urge.
• Don’t strain during a bowel movement or sit on the toilet for long periods. This puts more pressure on your veins.
• Keep a healthy weight.

Is It Hemorrhoids or Colon Cancer?

Although hemorrhoids and colon cancer are two very different conditions, they can share similar symptoms. This guide will help you learn about the different signs.

Noticing blood in your stool for the first time is understandably alarming. The good news is that it’s likely that blood in your stool is an indication of hemorrhoids, which while not much fun, aren’t generally a serious medical condition.

Hemorrhoids are actually swollen veins located in the anus and rectum area, and they’re quite common: Approximately half of all adults experience hemorrhoids by the age of 50. They can be internal (inside the rectum or anus) or external (on, or protruding from, the rectum or anus), and symptoms can range from no or mild discomfort to significant pain, itchiness and bleeding.

While the exact cause of hemorrhoids is unknown, they’re most likely to occur when there’s an increase in pressure in the area, such as when you strain to have a bowel movement, for example. They’re more likely to occur during pregnancy, aging, sitting for long periods of time, chronic constipation or diarrhea, straining or lifting heavy objects.

Hemorrhoids usually aren’t dangerous, and in many cases, the symptoms will go away within a few days.

Here are some of the most common signs and symptoms of hemorrhoids:

• Itching or irritation in the anal area
• Bright red blood on toilet tissue, stool or in the toilet bowl
• Pain or discomfort, especially during bowel movements
• A sensitive or painful lump(s) on or near your anus

To relieve symptoms, doctors recommend sitting in a lukewarm bath, alternating moist heat with ice and limiting extended periods of time spent sitting. There are also over-the-counter topical creams and suppositories to battle the symptoms. Patients are also advised to use scent- and dye-free toilet paper and to keep the area clean.

Colon cancer (also known as colorectal cancer) is a malignant tumor, arising from the inner wall of the large intestine. Signs and symptoms of colon cancer are often not specific, which means they may be mistaken for a number of different conditions. When colon cancer is detected in its early stages, there may be no symptoms present at all.

The usual symptoms and signs of colon cancer are:

• Rectal bleeding or blood in the stool
• Dark-colored stool
• A change in bowel habits, such as diarrhea, constipation or narrowing of the stool that lasts for more than a few days
• A feeling that you need to have a bowel movement that is not relieved by having one
• Cramping or abdominal (belly) pain
• Weakness and fatigue
• Unintended weight loss

In most cases, people who have these symptoms do not have cancer. Still, if you’re experiencing any of these symptoms, you should contact your doctor, so the cause can be found and treated.

To check for colon cancer, physicians use sigmoidoscopy or colonoscopy to look for growths (polyps) in the colon. If a growth is found, the physician will take a biopsy to determine whether the growth is cancerous. If you are diagnosed with colon cancer, treatment depends on how early it is found, but it may include surgery, radiation, chemotherapy and targeted therapies. Risk factors for colorectal cancer include a family history of colon polyps (small clump of cells that form on the lining of the colon) and long-standing inflammation of the large intestine.

Because the symptoms are often subtle and easily overlooked, colon cancer screening is very important. In fact, the American Cancer Society recommends starting regular screenings at age 45.

by Ramin Zahed

The Colorectal Cancer Program at USC Norris Comprehensive Cancer Center is one of the nation’s leading programs in cancer treatment and cancer genetics. If you are in the Los Angeles area, call  (800) USC-CARE (800-872-2273) or visit https://keckmedicine.org/request-an-appointment/ to schedule an appointment.

Hemorrhoids: Expanded Version | ASCRS

WHAT ARE HEMORRHOIDS?

It is important to note that all people have hemorrhoidal tissue as part of their normal anatomy. Only in a minority of people do hemorrhoids become enlarged or otherwise symptomatic. Hemorrhoidal tissue lies within the anal canal and perianal area and consists of blood vessels, connective tissue, and a small amount of muscle. 

There are two main types of hemorrhoids: internal and external.   Internal hemorrhoids are covered with a lining called mucosa that is not sensitive to touch, pain, stretch, or temperature, while external hemorrhoids are covered by skin that is very sensitive. When problems develop, these two types of hemorrhoids can have very different symptoms and treatments. 

SYMPTOMS

Roughly 5% of people will develop symptoms attributable to their hemorrhoids and only a small fraction of those patients will require surgical treatment. Patients may experience symptoms caused by either internal or external hemorrhoids or both. 

The majority of patients with anal symptoms seen in a colon and rectal surgeon’s office complain of hemorrhoids but a careful history and examination by an experienced physician is necessary to make a correct diagnosis. Some patients will have long-standing complaints that are not attributable to hemorrhoidal disease. Other serious diseases such as anal and colorectal cancer should be ruled out by a consultation with Colorectal provider who is knowledgeable in evaluating the anal and rectal area. 

INTERNAL HEMORRHOIDS

Painless rectal bleeding or prolapse of anal tissue is often associated with symptomatic internal hemorrhoids.  Prolapse is hemorrhoidal tissue coming from the inside that can often be felt on the outside of the anus when wiping or having a bowel movement. This tissue often goes back inside spontaneously or can be pushed back internally by the patient. The symptoms tend to progress slowly over a long time and are often intermittent. 

Internal hemorrhoids are classified by their degree of prolapse, which helps determine management:

Grade One: No prolapse

Grade Two: Prolapse that goes back in on its own

Grade Three: Prolapse that must be pushed back in by the patient

Grade Four: Prolapse that cannot be pushed back in by the patient (often very painful)

Bleeding attributed to internal hemorrhoids is usually bright red and can be quite brisk.   It may be found on the toilet paper, dripping into the toilet bowl, or streaked on the stool itself.  Not all patients with symptomatic internal hemorrhoids will have significant bleeding.  Instead, prolapse may be the main or only symptom. Prolapsing tissue may result in significant irritation and itching around the anus.  Patients may also complain of mucus discharge, difficulty with cleaning themselves after a stool, or a sense that their stool is “stuck” at the anus with BMs.  Patients without significant symptoms from internal hemorrhoids do not require treatment based on their presence alone. 

EXTERNAL HEMORRHOIDS

Symptomatic external hemorrhoids often present as a bluish-colored painful lump just outside the anus. They tend to occur spontaneously and may have been preceded by an unusual amount of straining. The skin overlying the outside of the anus is usually firmly attached to the underlying tissues. If a blood clot or thrombosis develops in this tightly held area, the pressure goes up rapidly in these tissues often causing pain. The pain is usually constant and can be severe. Occasionally the elevated pressure in the thrombosed external hemorrhoid results in breakdown of the overlying skin and the clotted blood begins leaking out. Patients may also complain of intermittent swelling, pressure and discomfort, related to external hemorrhoids which are not thrombosed. 

ANAL SKIN TAGS

Patients often complain of painless, soft tissue felt on the outside of the anus.  These can be the residual effect of a previous problem with an external hemorrhoid.  The blood clot stretches out the overlying skin and the skin remains stretched out after the blood clot is absorbed by the body, thereby leaving a skin tag.  Other times, patients will have skin tags without an obvious preceding event.  Skin tags will occasionally bother patients by interfering with their ability to clean the anus following a stool, while others just don’t like the way they look.  Usually, nothing is done to treat them beyond reassurance. However, surgical removal is occasionally considered. 

WHAT CAUSES SYMPTOMATIC HEMORRHOIDS?

The majority of factors thought to produce symptomatic hemorrhoids are associated with an increased pressure within the abdomen that gets transmitted to the anal region.  Some of these factors include: straining when having a bowel movement, constipation, diarrhea, pregnancy, and irregular bowel patterns.  It seems that, over time, these factors may contribute to the prolapse of internal hemorrhoidal tissue or enlargement of or thrombosis of external hemorrhoidal tissue. 

EXAMINATION

After obtaining a careful history regarding your symptoms and your personal and family medical history, your doctor will need to perform an examination in the office.  This usually consists of careful inspection of the outside of the anus, placement of a finger through the anus into the rectum (digital examination), and placement of a finger-sized instrument through the anus to allow visual inspection of the hemorrhoidal tissue (anoscopy).   Although it may not occur during the initial visit, your doctor may want to look even further upstream into the colon to rule out polyps, cancers, and other causes of bleeding.  A flexible sigmoidoscopy can visualize approximately half of your colon, while a colonoscopy usually allows for visualization of the entire colon.   

NON-SURGICAL TREATMENT OF INTERNAL HEMORRHOIDS

There are a wide variety of treatment options available for symptomatic internal hemorrhoids depending upon their grade (see above discussion) and the severity of your symptoms.  Often, adherence to the dietary and lifestyle changes detailed below will relieve symptoms.  However, if there is failure to respond to these changes alone, or if symptoms are severe enough at the outset, there are a number of office-based and surgical procedures available to alleviate symptoms. 

DIETARY/LIFESTYLE CHANGES

The cornerstone of therapy, regardless of whether surgery is needed or not, is dietary and lifestyle change.  The main changes consist of increasing dietary fiber, taking a fiber supplement, getting plenty of fluids by mouth, and exercising.  This is all designed to regulate, not necessarily soften, your bowel movements. The goal is to avoid both very hard stools and diarrhea, while achieving a soft, bulky, easily cleaned type of stool.  This type of stool seems to be the best kind to prevent anal problems of almost all kinds.  

It is usually recommended to achieve 20-35 grams of fiber per day in the diet, including plenty of fruits and vegetables.  Most people can benefit from taking a fiber supplement one to two times daily.  These supplements are available in powder, chewable, and capsule/tablet forms. Also important is adequate fluid (preferably water) consumption, often considered 8-10 glasses daily. Caffeinated drinks and alcohol tend to be dehydrating and therefore do not count toward this total. 

OFFICE-BASED THERAPIES FOR INTERNAL HEMORRHOIDS

The most commonly used office procedures are rubber band ligation, infrared coagulation, and sclerotherapy.   These treatment options are for internal hemorrhoids only and do not apply to external hemorrhoids. 

RUBBER BAND LIGATION

Rubber band ligation can be used for Grades 1, 2, and some Grade 3 internal hemorrhoids.  At the time the MD or APP performs the examination described above (anoscopy), a device can be placed through the anoscope, which can pull up the excessive internal hemorrhoidal tissue and place a rubber band at its base.  The band acts to cut off the hemorrhoid’s blood supply and the extra tissue falls off (with the band) at roughly 5-7 days, at which time there may be a small amount of bleeding.  If a patient is taking blood thinners such as Coumadin, Heparin, or Plavix, they may not be a candidate for this procedure.  Anywhere from one to three rubber bands per visit may be placed and several short visits may be required to achieve relief of symptoms. Rubber band placement is not associated with any significant recovery time for most people. Rubber bands can be associated with a dull ache or feeling of pressure lasting 1-3 days that is usually well-treated with Ibuprofen or Tylenol.  Upon completion of your banding session(s), you likely will not need further treatment, provided you continue the previously described dietary and lifestyle changes.  If your symptoms return, repeat banding certainly can be considered.  Hemorrhoidectomy is always an option if significant progress is not made with banding. Complications are very uncommon, but may include bleeding, pain and infection, among others. 

INFRARED PHOTOCOAGULATION

Infrared coagulation (IRC) is another office-base procedure, for Grades 1 and 2 and occasional Grade 3 internal hemorrhoids, which can be performed during anoscopy.  IRC utilizes infrared radiation generated by a small light that is applied to the hemorrhoidal tissue.  This energy is converted to heat and causes the hemorrhoidal tissue to become inflamed, slough off, and scar down, thereby eliminating this excess tissue.   This procedure is usually quick, painless, has few complications, but may take several short sessions to achieve relief of symptoms. 

SCLEROTHERAPY

Sclerotherapy is another office-based treatment for Grades 1 and 2 internal hemorrhoids.  It involves the injection of chemical irritants into the hemorrhoids, resulting in scarring and shrinkage by reducing the blood vessels present in the hemorrhoidal tissues.  Sclerotherapy is similarly quick, often painless, has few complications, and may take several short sessions to achieve relief of symptoms.  This has the potential to be used in patients taking blood thinners such as Coumadin, Heparin, or Plavix, but would need to be considered. 

OFFICE TREATMENT OF EXTERNAL HEMORRHOIDS

External hemorrhoids, which are not thrombosed, are generally managed symptomatically, with dietary management and topical agents. Only occasionally are they removed surgically but this cannot be done in the office. 

The pain associated with a symptomatic, thrombosed external hemorrhoid (see description above) often peaks about 48-72 hours after its onset and is largely resolving after roughly four-five days.  Pain is the indication to treat thrombosed external hemorrhoids and, therefore, the treatment will depend upon the timing from the initial thrombosis.  If you are improving significantly and your doctor is able to touch/pinch the involved external hemorrhoid without significant discomfort to you, then non-operative measures are used (warm baths, pain-relieving creams and pills, and fiber therapy described above).  If a patient presents in severe pain, an office-based surgical procedure may be offered.  This involves the injection of local anesthesia (“numbing medicine”) and removing the blood clot and overlying skin.  

OPERATIVE TREATMENT OF HEMORRHOIDS

Fewer than 10% of all patients evaluated with symptomatic hemorrhoids will require surgical management. Most patients respond to non-operative treatment and do not require a surgical procedure. Hemorrhoidectomy, or surgical removal of the hemorrhoidal tissue, may be considered if a patient presents with symptomatic large external hemorrhoids, combined internal and external hemorrhoids, and/or grade 3-4 prolapse.  Hemorrhoidectomy is highly effective in achieving relief of symptoms and it is uncommon to have any significant recurrence.  However, it also causes much more pain and disability than office procedures and has somewhat more complications. 

Hemorrhoidectomy may be done using a variety of different techniques and instruments to remove the hemorrhoids and the particular technique is usually chosen based on a particular surgeon’s preference.  In basic terms, the excess hemorrhoidal tissue is removed and the resultant wound may be closed or left open.  Hemorrhoidectomy is performed in an operating room and may be done under sedation, general anesthesia, or under a spinal block (similar to an epidural injection during childbirth).   

In an attempt to avoid some of the postoperative pain associated with hemorrhoidectomy, a stapled or suture hemorrhoidopexy may be considered and involves pulling the hemorrhoids upward, returning the problematic hemorrhoidal tissue to its normal position. All operative procedures for hemorrhoidal disease carry their own set of risks and benefits and the ultimate choice of procedure must be made between you and your surgeon.   

POSTOPERATIVE INSTRUCTIONS

Pain can be expected following hemorrhoid surgery.  The goal is to make it manageable, but it may be up to 2-4 weeks before one is able to resume your full level of activities.  Pain medication is usually a combination of narcotic and non-narcotic medicine and the goal is to limit the amount and number of days a patient takes stronger narcotic medications. Sitting in a bath (sitz bath) 2–3 times daily for 10-15 minutes per time in warm water can be quite helpful.  Occasionally, patients will have difficulty urinating after anorectal surgery.  If unable to void, the patient should try urinating in the tub during a sitz bath.  If that does not work, a patient should be instructed to contact the Surgeon’s office and/or proceed to an emergency department for placement of a catheter in the bladder.  Failure to do so can result in permanent bladder damage from over-stretching.  

Bowel movements after hemorrhoid surgery is a concern for patients.  Most colon and rectal surgeons recommend having a stool within the first 48 hours after surgery.  A high fiber diet, a fiber supplement, and increased liquid intake are advised.  If this does not produce a stool, laxatives may be indicated.  Occasionally, a second procedure has to be done under anesthesia to remove (disimpact) the stool.   

WHAT IS A COLON AND RECTAL SURGEON?

Colon and rectal surgeons are experts in the surgical and non-surgical treatment of diseases of the colon, rectum and anus. They have completed advanced surgical training in the treatment of these diseases as well as full general surgical training. Board-certified colon and rectal surgeons complete residencies in general surgery and colon and rectal surgery, and pass intensive examinations conducted by the American Board of Surgery and the American Board of Colon and Rectal Surgery. They are well-versed in the treatment of both benign and malignant diseases of the colon, rectum and anus and are able to perform routine screening examinations and surgically treat conditions if indicated to do so.

DISCLAIMER

The American Society of Colon and Rectal Surgeons is dedicated to ensuring high-quality patient care by advancing the science, prevention and management of disorders and diseases of the colon, rectum and anus. These brochures are inclusive but not prescriptive. Their purpose is to provide information on diseases and processes, rather than dictate a specific form of treatment. They are intended for the use of all practitioners, health care workers and patients who desire information about the management of the conditions addressed. It should be recognized that these brochures should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtain the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient.

Colon and Rectal Conditions | Hemorrhoids

Almost everyone will get hemorrhoids at some point in their life. Most of the time, symptoms go away on their own, after a few days, even without treatment. On occasion, your hemorrhoid condition is complex and needs a doctor’s attention. That’s where we can help.

Hemorrhoids are enlarged or swollen veins in the bottom of the rectum or the anus. They do not usually cause serious health problems. But they can be annoying and uncomfortable.

Hemorrhoids are common, occurring in both men and women. They are more common in people:

• Pelvic tumors
• Pregnancy, both during or after
• Sendenaty people, or those who sit for prolonged periods of time
• Those who have diarrhea or constipation
• Who are older

Treatment consists of dietary changes and having regular bowel habits. If your hemorrhoids are large, do not go away on their own or you have many hemorrhoids, you may need surgery.

Causes of hemorrhoids

In general the cause of hemorrhoids is increased pressure on the veins in the pelvis and rectal area. The cause of this can be:

• Excessive straining found with chronic constipation
• Excessive straining found with chronic diarrhea
• Pregnancy, due to pressure in the pelvis from the baby in the uterus
• Obesity
• Prolonged daily sitting like with truck drivers or other sedentary professions

Symptoms of hemorrhoids

The most common symptoms of hemorrhoids include the following:

• Painless rectal bleeding, usually is a small amount
• Anal itching or pain, due to irritation of the skin surrounding the anus
• Tissue bulging around the anus, some people can see or feel hemorrhoids on the outside of the anus
• Leakage of feces or difficulty cleaning after a bowel movement

Rectal bleeding

Many people with hemorrhoids notice bright red blood on the stool, in the toilet or on the tissue after a BM. The amount of blood is usually small. Yet even a small amount of blood can cause the water to appear bright red. This can be frightening.

Less common is heavy bleeding.

While hemorrhoids are one of the most common reasons for rectal bleeding, there are other, more serious causes. It is not possible to know what is causing rectal bleeding unless you have an examination. You should seek medical attention if you see bleeding after a bowel movement.

Rectal pain

Hemorrhoids can become painful. If you develop severe pain, call your healthcare provider immediately. This may be a sign of a serious problem.

Testing for hemorrhoids

Often your doctor can determine if you have hemorrhoids by asking about your symptoms and doing a physical examination.

Your doctor will do a digitial rectal examination, an exam using a gloved finger inside your rectum. You may need to do an anoscopy. This is where your doctor inserts a short, lighted scope into your anus and exams the inside of your anal canal. You may need to have a Colonoscopy or sigmoidoscopy for further testing.

Hemorrhoids hidden inside the rectum are “internal” hemorrhoids. You cannot see them, but they can cause symptoms.

Hemorrhoids that you can see or feel are “external” hemorrhoids.

Reproduced with permission from: Patient Information: Hemorrhoids (The Basics). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA 2012. Copyright © 2012 UpToDate, Inc. For more information visit www.uptodate.com.

Hemorrhoid types

External hemorrhoids are visible on the outside of the anus and originate in the lower part of the anus. These can become inflammed and the blood inside the veins can become clotted. This is a thrombosed, or clotted, hemorrhoid.

Internal Hemorrhoids are generally not visible on the outside. This is because they originate higher up in the anal canal. Internal hemorrhoids more commonly cause bleeding after a bowel movement.

If internal hemorrhoids become large and severe, they can push out through the anus, becoming visible. This can be very painful. This is especially true if the hemorrhoid becomes trapped in the anal muscle and cannot go back inside.

Classification of Internal Hemorrhoids:

• Grade 1 (minor) – A hemorrhoid is present but only visualized by a doctor with ansocopy or colonoscopy. The hemorrhoid does not extend out the anus.
• Grade 2 – The hemorrhoid(s) extends out of the anus with a bowel movement or with straining. After your BM, the hemorrhoid goes back inside on its own.
• Grade 3 – The hemorrhoid(s) extends out of the anus with a bowel movement or with straining. You have to manually push the hemorrhoid back inside the anus. If you have this, you should seek medical attention, but it is not urgent.
• Grade 4 (severe) – A hemorrhoid(s) extends outside the anus and are not able to be manually pushed back inside. If you have this seek medical attention immediately. There are significant potential complications.

Hemorrhoid treatment

Most of the time, hemorrhoid symptoms go away after a few days even without treatment. If not, treatment focuses on relieving the pain.

After hemorrhoid surgery

This is generally a same-day surgery. Most people are able to return to work and other activities in about 1-2 weeks. You may have a small amount of bleeding on the dressing or after having a bowel movement. This can last for a couple weeks. You should contact your doctor if the bleeding is more than a few Tablespoons per day.

You may resume your usual diet immediately after surgery.

It is very important to not allow yourself to become constipated after surgery. To avoid constipation, we recommend:

• Starting a diet of high fiber the morning after surgery. Bran cereal, wheat or rye bread, fresh fruits, and vegetables are ideal.
• Mixing one tablespoon of Metamucil with eight ounces of water twice a day. You should start this on the morning after surgery.
• Taking Dulcolax stool softener (100mg) twice daily. This starts on the day before your surgery, and until you are no longer taking pain medication.
• If you go 48 hours without a bowel movement (BM), take two tablespoons of Milk of Magnesia. Continue taking every 6 hours until your first BM, and then stop.
• Call the office if you go more than 2 days without a BM or if you are having abdominal pain or abdominal distension.
• Drink plenty of water and juice and eat fresh fruits and vegetables.

Hemorrhoids | Piles | MedlinePlus

What are hemorrhoids?

Hemorrhoids are swollen, inflamed veins around your anus or the lower part of your rectum. There are two types:

• External hemorrhoids, which form under the skin around your anus
• Internal hemorrhoids, which form in the lining of your anus and lower rectum

What causes hemorrhoids?

Hemorrhoids happen when there is too much pressure on the veins around the anus. This can be caused by

• Straining during bowel movements
• Sitting on the toilet for long periods of time
• Chronic constipation or diarrhea
• A low-fiber diet
• Weakening of the supporting tissues in your anus and rectum. This can happen with aging and pregnancy.
• Frequently lifting heavy objects

What are the symptoms of hemorrhoids?

The symptoms of hemorrhoids depend on which type you have:

With external hemorrhoids, you may have

• Anal itching
• One or more hard, tender lumps near your anus
• Anal pain, especially when sitting

Too much straining, rubbing, or cleaning around your anus may make your symptoms worse. For many people, the symptoms of external hemorrhoids go away within a few days.

With internal hemorrhoids, you may have

• Bleeding from your rectum – you would see bright red blood in your stool, on toilet paper, or in the toilet bowl after a bowel movement
• Prolapse, which is a hemorrhoid that has fallen through your anal opening

Internal hemorrhoids are usually not painful unless they are prolapsed. Prolapsed internal hemorrhoids may cause pain and discomfort.

How can I treat hemorrhoids at home?

You can most often treat your hemorrhoids at home by

• Eating foods that are high in fiber
• Taking a stool softener or a fiber supplement
• Drinking enough fluids every day
• Not straining during bowel movements
• Not sitting on the toilet for long periods of time
• Taking over-the-counter pain relievers
• Taking warm baths several times a day to help relieve pain. This could be a regular bath or a sitz bath. With a sitz bath, you use a special plastic tub that allows you to sit in a few inches of warm water.
• Using over-the-counter hemorrhoid creams, ointments, or suppositories to relieve mild pain, swelling, and itching of external hemorrhoids

When do I need to see a health care provider for hemorrhoids?

You should see your health care provider if you

How are hemorrhoids diagnosed?

To make a diagnosis, your health care provider

• Will ask about your medical history
• Will do a physical exam. Often providers can diagnose external hemorrhoids by looking at the area around your anus.
• Will do a digital rectal exam to check for internal hemorrhoids. For this, the provider will insert a lubricated, gloved finger into the rectum to feel for anything that is abnormal.
• May do procedures such as an anoscopy to check for internal hemorrhoids

What are the treatments for hemorrhoids?

If at-home treatments for hemorrhoids don’t help you, you may need a medical procedure. There are several different procedures that your provider can do in the office. These procedures use different techniques to cause scar tissue to form in the hemorrhoids. This cuts off the blood supply, which usually shrinks the hemorrhoids. In severe cases, you may need surgery.

Can hemorrhoids be prevented?

You can help prevent hemorrhoids by

• Eating foods that are high in fiber
• Taking a stool softener or a fiber supplement
• Drinking enough fluids every day
• Not straining during bowel movements
• Not sitting on the toilet for long periods of time

NIH: National Institute of Diabetes and Digestive and Kidney Diseases

Hemorrhoids and What To Do About Them

Hemorrhoids are sometimes described as varicose veins in the lower rectum or anus. They’re very common, and almost three out of four adults will have them at some point during their lives. Hemorrhoids can be internal or external. Internal hemorrhoids are swollen veins that develop inside the rectum. External hemorrhoids are swollen veins under the skin around the anus.

You can experience differing symptoms depending on the location of your hemorrhoids. Signs and symptoms of external hemorrhoids can include:

• Irritation and itching in and around your anus

• Pain and discomfort

• Swelling around your anus

• Bleeding

• Sensitive lumps in your anal area

Unlike external hemorrhoids, internal hemorrhoids usually can’t be seen, and often don’t cause obvious symptoms until or unless you’re having a bowel movement.

Why do I have blood on the toilet paper after wiping?

If you’ve noticed bright red blood in the toilet or on toilet paper after a bowel movement, it may be from an internal hemorrhoid. Hemorrhoids can cause bright red blood during bowel movements. Blood on toilet paper may also result from an anal fissure, a small tear in the lining of your anus.

Why am I experiencing rectal bleeding without pain?

Bleeding in your lower gastrointestinal tract, including the lower colon and rectum, can occur without pain. Hemorrhoids are the most common cause of painless rectal bleeding, but don’t presume this to be THE diagnosis. You should speak with your doctor if you have painful, itching hemorrhoids or rectal bleeding without pain. Rectal bleeding can have other causes, including anal cancer and colorectal cancer. 

Can a colonoscopy distinguish hemorrhoids from colon cancer?

A colonoscopy uses an endoscope, a flexible tube that guides a fiber optic camera through your colon. A colonoscopy can quickly discover any internal hemorrhoids and other problems including colon cancer. Hemorrhoids are swollen veins, and doctors can immediately distinguish between them, anal fissures, colon polyps, or colon cancer.

Colon polyps are growths in the lining of your colon that can be an indication you could be at risk from colon cancer. They can be quickly and easily removed during a colonoscopy. 

A colonoscopy is one of several tests that can uncover the reason you’ve experienced rectal bleeding. The first, simplest test is a rectal examination. You can’t see the inside of your rectum easily, but a clinician can. 

Other tests include an anoscopy and a sigmoidoscopy. These are minimally invasive tests that don’t require you to be sedated. A colonoscopy is a more extensive procedure and requires sedation.

If you do need a colonoscopy, your Digestive Health Associates of Texas can perform one. It’s a simple procedure which lasts about two hours. The test can remove polyps and other potentially abnormal tissue that the colonoscopy scope sees during the procedure.

What should I do if I have hemorrhoids?

If you experience any rectal bleeding, you should contact your doctor. If you know you’ve had hemorrhoids before and experience itching and swelling in your anal area, your hemorrhoids may be acting up. There are health risks associated with hemorrhoids, as common as they are. Internal hemorrhoids can prolapse or protrude from your anus. Blood can also pool in a hemorrhoid and thrombose — the medical term for a blood clot.

Are there things I can do to help my hemorrhoids?

One of the best things you can do if you have hemorrhoids is improve your bowel habits. Don’t avoid going to the bathroom: use it when you need it. Hemorrhoids can result from sitting on the toilet for long periods, so it’s wise to avoid reading while in the bathroom. Sit only as long as you need to, and wipe gently with unscented toilet paper or cleansing wipes. While scent in toilet paper and wipes can cover unpleasant bathroom odors, fragrance can irritate your skin: the last thing you need if you have hemorrhoids.

Hemorrhoids are associated with constipation, which is the reason why clinicians tell people to get more fiber in their diet. High-fiber foods include fresh fruits and vegetables, whole-grain breads, and wheat bran. Drinking enough water is also important to help prevent constipation. 

Getting enough exercise is also important to improve or prevent constipation. Getting at least half an hour a day of moderate exercise could help you to improve or prevent hemorrhoids.

For a hemorrhoid flare-up, you can also take a sitz bath, which means sitting in a few inches of warm, not hot, bath water. Soaking for ten minutes can relieve itching and burning that accompanies hemorrhoids. A well-insulated ice pack can also reduce swelling and pain. Always make sure you have a cloth barrier between the ice pack and your skin to prevent skin damage. 

You can locate over-the-counter topical treatment creams that can reduce itching and swelling. Other treatments are also available, including hydrocortisone suppositories. Mild astringents like witch hazel can also relieve hemorrhoid burning and itching. You can reduce short-term pain with oral pain relievers like acetaminophen or ibuprofen.

Hemorrhoids can be treated, and DHAT can help

A colonoscopy may not be essential to diagnose hemorrhoids, but it can determine if you have hemorrhoids, colon polyps, colon cancer, or other problems in your lower digestive tract. Colonoscopies are simple procedures. According to iData Research, approximately 19 million colonoscopies are performed in the U.S. every year.

Colonoscopies are non-invasive, safe medical procedures. They can help to determine the health of your lower digestive tract. DHAT is experienced in performing colonoscopies. They can schedule a colonoscopy for you and are glad to explain how you can prepare for the procedure, how it will be conducted, and the results you can expect to obtain. 

You may not need any surgery for hemorrhoids, but it you do, DHAT can also perform procedures that can reduce the pain and discomfort of hemorrhoids and help you return to a pain and itch-free life. Bowel movements aren’t the most pleasant topic, but they’re a part of life for everyone. Don’t let hemorrhoids interfere with your comfort, your career, or an active, healthy lifestyle. 

About half of people over age 50 experience problems with hemorrhoids. You may not have known, but everyone has hemorrhoids; which are technically areas of blood vessels which form a cushion in our anal canals. However, we only become aware of these blood vessels if they cause problems by becoming swollen, irritated, or bleeding. If you see blood in your bowel movement or on toilet tissue, contact your doctor. Hemorrhoids are easily treated, and a colonoscopy can also help to protect you from other conditions in addition to hemorrhoids.

If you do need a colonoscopy, your DHAT doctor can schedule and perform one for you. It’s a relatively simple, out-patient procedure that in most cases will take only a couple hours of your day.  And during the procedure, your doctor can remove any polyps or other potentially abnormal tissue for further testing.  To meet with a DHAT physician near you,  make an appointment online,  or call 1.800.818.8541.

Sources

https://fascrs.org/patients/diseases-and-conditions/a-z/hemorrhoids

https://www.mayoclinic.org/diseases-conditions/hemorrhoids/diagnosis-treatment/drc-20360280

https://www.healthgrades.com/right-care/digestive-health/when-to-see-a-doctor-for-blood-in-stool

https://colquittregional.com/about/news/Can-you-ignore-rectal-bleeding

An Astounding 16.6 Million Colonoscopies are Performed Annually in The United States

https://www.livescience.com/40316-americans-interest-hemorrhoids.html

Treatment of hemorrhoids: A coloproctologist’s view

World J Gastroenterol. 2015 Aug 21; 21(31): 9245–9252.

Varut Lohsiriwat, Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand

Author contributions: Lohsiriwat V solely contributed to this article.

Correspondence to: Varut Lohsiriwat, MD, PhD, Associate Professor of Surgery, Division of Colon and Rectal Surgery, Department of Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang-Lung Road, Bangkok Noi, Bangkok 10700, Thailand. moc.liamtoh@noollob

Telephone: +66-2419-8005 Fax: +66-2412-1370

Received 2015 Jan 26; Revised 2015 Apr 21; Accepted 2015 Jul 3.

Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.This article has been cited by other articles in PMC.

Abstract

Hemorrhoids is recognized as one of the most common medical conditions in general population. It is clinically characterized by painless rectal bleeding during defecation with or without prolapsing anal tissue. Generally, hemorrhoids can be divided into two types: internal hemorrhoid and external hemorrhoid. External hemorrhoid usually requires no specific treatment unless it becomes acutely thrombosed or causes patients discomfort. Meanwhile, low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures (such as rubber band ligation and injection sclerotherapy). Surgery is indicated for high-graded internal hemorrhoids, or when non-operative approaches have failed, or complications have occurred. Although excisional hemorrhoidectomy remains the mainstay operation for advanced hemorrhoids and complicated hemorrhoids, several minimally invasive operations (including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation and stapled hemorrhoidopexy) have been introduced into surgical practices in order to avoid post-hemorrhiodectomy pain. This article deals with some fundamental knowledge and current treatment of hemorrhoids in a view of a coloproctologist – which includes the management of hemorrhoids in complicated situations such as hemorrhoids in pregnancy, hemorrhoids in immunocompromised patients, hemorrhoids in patients with cirrhosis or portal hypertension, hemorrhoids in patients having antithrombotic agents, and acutely thrombosed or strangulated hemorrhoids. Future perspectives in the treatment of hemorrhoids are also discussed.

Keywords: Hemorrhoids, Pathophysiology, Treatment, Outcome, Complication

Core tip: Hemorrhoids is a very common anorectal disease defined as the symptomatic enlargement and/or distal displacement of anal cushions. Apart from abnormally dilated vascular channel and destructive changes in supporting tissue within anal cushions, there is emerging evidence that hemorrhoids is associated with hyperperfusion state of anorectal region and some degree of tissue inflammation. This article comprehensively and thoroughly reviews the pathophysiology, clinical diagnosis, and current treatment of hemorrhoids – which includes dietary and lifestyle modification, pharmacological approach, office-based procedures and operations for hemorrhoids (such as hemorrhoidectomy and other non-excisional surgery). The management of hemorrhoids in complicated situations is also addressed.

INTRODUCTION

Hemorrhoids is a very common anorectal disease defined as the symptomatic enlargement and/or distal displacement of anal cushions[1,2], which are prominences of anal mucosa formed by loose connective tissue, smooth muscle, arterial and venous vessels[3]. The true prevalence of hemorrhoids is unknown; however, recent evidence has suggested an increasing prevalence of hemorrhoids over time. In 1990, an epidemiologic study of hemorrhoids in the United State revealed a prevalence rate of 4.4%, whereas some reports in the 21^st century from South Korea and Austria yielded a prevalence of hemorrhoids in adult population of 14.4%[4] and 38.9%[5], respectively. It has been estimated that 25% of British people and 75% of American citizens will experience hemorrhoids at some time in their lives[6,7], especially in pregnant women and elderly adults.

People with hemorrhoids, and those wrongly thought to have hemorrhoids, had a tendency to use self-medication rather than to seek proper medical attention[8]. According to the Google’s annual roundup in 2012 (Google Zeitgeist), hemorrhoids was the top trending heath issue in the United State, ahead of gastroesophageal reflux disease and sexually transmitted disease. Unfortunately, the quality of information about hemorrhoids treatment on the internet was greatly variable and almost 50% of websites were of poor quality[9]. Clinicians should therefore advise and treat patients with hemorrhoids with evidence-based medicine and the standard of care. Practically, most patients with low-graded hemorrhoids can be effectively treated with non-operative measures by either primary care physician, gastroenterologist or general surgeon in an outpatient setting. Surgery is indicated for high-graded hemorrhoids, or when non-operative approaches have failed, or complications have occurred[2]. This article deals with some fundamental knowledge and current treatment of uncomplicated and complicated hemorrhoids in a view of a coloproctologist.

CONTEMPORARY PATHOPHYSIOLOGY OF HEMORRHOIDS

The exact pathophysiology of hemorrhoids is poorly understood. Currently, hemorrhoids is the pathologic term describing symptomatic and abnormally downward displacement of normal anal cushions[2]. As a result of destructive changes in the supporting connective tissue and abnormal blood circulation within anal cushions, the sliding anal cushions embrace abnormal dilation and distortion of hemorrhoid plexus. A recent study of morphology and hemodynamic of arterial supply to the anal canal revealed a hyperperfusion state of hemorrhoidal plexus in patients with hemorrhoids[10], suggesting the dysregulation of vascular tone within hemorrhoid tissue[1,2]. Moreover, it was evident that hemorrhoidal tissue contained some inflammatory cells[11] and newly-formed microvessels[12]. For circumferential prolapsing hemorrhoids, these might be related to an internal rectal prolapse[13]. In conclusion, although the true pathophysiology of hemorrhoid development is unknown, it is likely to be multifactorial[2] – including sliding anal cushion, hyperperfusion of hemorrhoid plexus, vascular abnormality, tissue inflammation and internal rectal prolapse (rectal redundancy). The different philosophies of hemorrhoid development may lead to different approaches to the treatment of hemorrhoids[2].

RISK FACTORS FOR HEMORRHOIDS

Several risk factors have been claimed to be the etiologies of hemorrhoid development including aging, obesity, abdominal obesity, depressive mood and pregnancy[4]. Meanwhile, some conditions related to increased intraabdominal pressure, such as constipation and prolonged straining, are widely believed to cause hemorrhoids as a result of compromised venous drainage of hemorrhoid plexus[14]. Some types of food and lifestyle, including low fiber diet, spicy foods and alcohol intake, was reported to link with the development of hemorrhoids and the aggravation of acute hemorrhoid symptoms[15].

DIAGNOSIS AND CLASSIFICATION OF HEMORRHOIDS

The most common presentation of hemorrhoids is painless rectal bleeding during defecation with or without prolapsing anal tissue. The blood is normally not mixed in stool but instead coated on the outer surface of stool, or it is seen during cleansing after bowel movement. The blood is typically bright red since hemorrhoid plexus has direct arteriovenous communication[10]. Patients with complicated hemorrhoids such as acutely thrombosed external hemorrhoids and strangulated internal hemorrhoids may present with anal pain and lump at the anal verge. It is uncommon that patients with uncomplicated hemorrhoid manifest any anal pain. In fact, severe anal pain in patient with hemorrhoids is more likely due to anal fissure and anorectal abscess[2].

A precise history and thorough physical examination, including digital rectal examination and anoscopy, are imperative for the diagnosis of hemorrhoids. Unless bright red blood is clearly seen from hemorrhoids, any patients with rectal bleeding should be scheduled for flexible sigmoidoscopy or colonoscopy, especially those being at risk of colorectal cancer[1,2].

Hemorrhoids are generally classified by their location; internal (originates above the dentate line and covered by anal mucosa), external (originates below the dentate line and covered by anoderm) and mixed type. Internal hemorrhoids are further graded based on their appearance and degree of prolapse: (1) Grade I: non-prolapsing hemorrhoids; (2) Grade II: prolapsing hemorrhoids on straining but reduce spontaneously; (3) Grade III: prolapsing hemorrhoids requiring manual reduction; and (4) Grade IV: non-reducible prolapsing hemorrhoids which include acutely thrombosed, incarcerated hemorrhoids[16].

MANAGEMENT OF HEMORRHOIDS

Treatment options mainly depend on the type and severity of hemorrhoids, patient’s preference and the expertise of physicians. Low-graded internal hemorrhoids are effectively treated with dietary and lifestyle modification, medical treatment and/or office-based procedures such as rubber band ligation and sclerotherapy (Figure ). An operation is usually indicated in low-graded hemorrhoids refractory to non-surgical treatment, high-graded hemorrhoids, and strangulated hemorrhoids[2]. Meanwhile, external hemorrhoid requires no specific treatment unless it becomes acutely thrombosed or causes patient discomfort.

Current treatment of internal hemorrhoids based on their severity and degree of prolapse. DG-HAL: Doppler-guided hemorrhoidal artery ligation; SH: Stapled hemorrhoidopexy; PPH: Procedure for prolapse and hemorrhoids.

Dietary and lifestyle modification

A meta-analysis of 7 clinical trials comprising of 378 patients with hemorrhoids showed that fiber supplement had a consistent benefit of relieving symptom and minimizing risk of bleeding by approximately 50%[17]. Although there is relatively little information of the efficacy of dietary and lifestyle modification on the treatment of hemorrhoids, many physicians include advice on dietary and lifestyle modification as a part of conservative treatment of hemorrhoids and as a preventive measure. The advice usually includes increasing the intake of dietary fiber and oral fluid, having regular exercise, refraining from straining and reading on the toilet, and avoiding drug causing constipation or diarrhea.

Medical treatment

The main goal of medical treatment is to control acute symptoms of hemorrhoids rather than to cure the underlying hemorrhoids. There are several modern drugs and traditional medicine used which are available in a variety of format including pill, suppository, cream and wipes. However, the published literature lacks strong evidence supporting the true efficacy of topical treatment for symptomatic hemorrhoids. For an oral preparation, flavonoids are the most common phlebotonic agent used for treating hemorrhoids[18]. It is apparent that flavonoids could increase vascular tone, reduce venous capacity, decrease capillary permeability, facilitate lymphatic drainage and has anti-inflammatory effects[2]. A large meta-analysis of phlebotonics for hemorrhoids in 2012 showed that phlebotonics had significant beneficial effects on bleeding, pruritus, discharge and overall symptom improvement. Phlebotonics also alleviated post-hemorrhoidectomy symptoms[19].

Office-based procedures

Many office-based procedures (such as rubber band ligation, injection sclerotherapy, infrared coagulation, cryotherapy, radiofrequency ablation and laser therapy) are effectively performed for grade I- II hemorrhoids and some cases of grade III hemorrhoids with or without local anesthesia. Among several office-based procedures, rubber band ligation (RBL) appeared to have the lowest incidence of recurrent symptom and the need for retreatment[20]. RBL is also the most popular non-surgical intervention for hemorrhoids performed by surgeons[21]. It is a relatively safe and painless procedure with minimal complication. However, RBL is contraindicated in patient with anticoagulants or bleeding disorder, and those with concurrent anorectal sepsis. With a technical note, the proper position of rubber band should be at the base of hemorrhoid bundle or over the bleeding site, but not too close to the dentate line. Vacuum suction ligator may offer clearer visualisation of hemorrhoids and more precise placement of banding when compared to a traditional forcep ligator[22]. Multiple sites and serial sessions of banding may be required for large internal hemorrhoids.

Operative treatment

Surgical intervention is usually required in low-graded hemorrhoids refractory to non-surgical treatment, high-graded symptomatic hemorrhoids, and hemorrhoids with complication such as strangulation and thrombosis. An operation for hemorrhoids may be performed if patient has other concomitant anorectal conditions requiring surgery, or due to patient’s preference.

An ideal operation for hemorrhoids should remove internal and external component of hemorrhoids completely, have minimal postoperative pain and complication, demonstrate less recurrence, and are easy to learn and perform. The procedure could be cheap and cost-effective too. Unfortunately, none of the currently available operation achieves all the ideal conditions. So far, excisional hemorrhoidectomy is the mainstay operation for grade III-IV hemorrhoids and complicated hemorrhoids. Of note, closed (Ferguson) hemorrhoidectomy and open (Milligan-Morgan) hemorrhoidectomy were equally effective and safe[23,24], but the Ferguson method was superior to the Milligan-Morgan method in term of long time patient satisfaction and continence[25]. Nevertheless, both techniques may lead to severe postoperative pain[26]. In order to minimize or avoid post-hemorrhoidectomy pain, more recent approaches including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation and stapled hemorrhoidopexy have been adopted into the surgical treatment of hemorrhoids. In addition, perioperative care for hemorrhoids has been significantly improved[1,27].

Surgical excision of hemorrhoids can be done by a variety of instrument such as a scalpel, scissors (Figure ), a cautery device, and more recently Ligasure^TM – a vessel sealing device (Figure ). A recent Cochrane Review demonstrates that Ligasure hemorrhoidectomy resulted in shorter operative time, less postoperative pain, and shorter convalescence period when compared to conventional hemorrhoidectomy[28]. Meanwhile, there was no significant difference in postoperative complications and long-term outcomes between the two techniques. Excisional hemorrhoidectomy can be performed safely in a day-case basis under the perianal infiltration of local anesthetics[29], or regional anesthesia, or general anesthesia. It is evident that some medications could decrease post-hemorrhoidectomy pain such as perioperative analgesia with oral non-steroidal anti-inflammatory drugs[30] and gabapentin[31], topical administration of sucralfate[32] or metronidazole[33], and postoperative administration of phlebotonic drugs[19].

Hemorrhoidectomy by (A) scissors and (B) Ligasure ^TM – a vessel sealing device.

Non-excisional operation for hemorrhoids includes doppler-guided hemorrhoidal artery ligation (DG-HAL) or known as transanal hemorrhoidal dearterialization (THD), and plication of hemorrhoids (or known as ligation anopexy or mucopexy). DG-HAL has been introduced into a surgical practice to cut off the blood supply to hemorrhoids without the need of hemorrhoid removal. It involves the surgical ligation of terminal branches of superior hemorrhoidal artery causing shrinkage of hemorrhoid bundles. Plication of hemorrhoids is often performed with DG-HAL to control the prolapse more effectively. However, the recurrence rate following DG-HAL was up to 60% for grade IV hemorrhoids. DG-HAL is therefore considered as one of the effective operations only for grade II-III hemorrhoids with a one-year recurrence rate of 10% for prolapse and 10% for bleeding[34]. Notably, DG-HAL is not a totally painless operation as approximately 20% of patients experienced postoperative pain especially during the defecation[34]. Meanwhile, a ligation anopexy or mucopexy was also demonstrated to be a good alternative to excisional hemorrhoidectomy for grade II-III hemorrhoids, with shorter operative time and lower postoperative pain[35]. Given the fact that there is the possibility of revascularization and recurrent prolapse, further studies on the long-term outcomes of non-excisional operations for hemorrhoids are needed.

Stapled hemorrhoidopexy, also known as a procedure for prolapse and hemorrhoids (PPH), is an alternative operation for treating advanced internal hemorrhoids. A circular staple device is used to excise a ring of redundant rectal mucosa just above hemorrhoid bundles – not hemorrhoids per se. By doing this, prolapsing hemorrhoids will be repositioning (hemorrhoidopexy) and shrinking (due to a partial interruption of blood supply to hemorrhoid plexus). A recent systematic review of 27 randomized controlled trials demonstrated that, compared with conventional hemorrhoidectomy, stapled hemorrhoidopexy had less pain, shorter operative time, and quicker patient’s recovery of patient, but a significantly higher rate of prolapse and reintervention for prolapse[36]. Interestingly, the latest meta-analysis comparing surgical outcomes between stapled hemorrhoidopexy and Ligasure hemorrhoidectomy in 2013 revealed that both surgical techniques were practically comparable – with a slightly favorable immediate postoperative results and technical advantages for Ligasure hemorrhoidectomy[37].

Given the fact that stapled hemorrhoidopexy did not offer any significant advantages over Ligasure hemorrhoidectomy[37] and it is a relatively expensive operation which may cause serious postoperative complications such as rectal stricture and rectal perforation[38] as well as severe chronic anal pain[39], stapled hemorrhoidopexy should be reserved for patients with circumferential prolapsing hemorrhoids and it must be performed by a well-trained surgeon[2].

SPECIFIC CONSIDERATION

Acutely thrombosed or strangulated internal hemorrhoids

Patients with acutely thrombosed or strangulated internal hemorrhoids usually present with severely painful and irreducible hemorrhoids. The incarcerated hemorrhoids may become necrotic and drain. This situation is quite difficult to treat particularly in a case of extensive strangulation or thrombosis (Figure ), or the presence of underlying circumferential prolapse of high-graded hemorrhoids. Manual reduction of the hemorrhoid masses, with or without intravenous analgesia or sedation, might help reducing pain and tissue congestion. Urgent hemorrhoidectomy is usually required in these circumstances. Unless the tissues are necrotic, mucosa and anoderm should be preserved as much as possible to prevent postoperative anal stricture. In expert hands, surgical outcomes of urgent hemorrhoidectomy were comparable to those of elective hemorrhoidectomy[40].

Complicated hemorrhoids. A: Strangulated internal hemorrhoid; B: Acutely thrombosed external hemorrhoid.

Acutely thrombosed external hemorrhoids

Acutely thrombosed external hemorrhoids often develop in patients with acute constipation, or those with a recent history of prolonged straining. A painful bluish-colored lump at the anal verge is a paramount finding (Figure ). The severity of pain is most intense within the first 24-48 h of onset. After that, the thrombosis will be gradually absorbed and patients will experience less pain. As a result, surgical removal of acute thrombus or excisional hemorrhoidectomy may be offered if patients experience severe pain especially within the first 48 h of onset. Otherwise, conservative measure will be exercised including pain control, warm sitz baths, and avoidance of constipation or straining. A resolving thrombosed external hemorrhoid could leave behind as a residual perianal skin tag -which may or may not require a subsequent excision.

Hemorrhoids in pregnancy

Hemorrhoids are very common during pregnancy especially in the third trimester[41]. Acute crisis such as profound bleeding and irreducible prolapsing may be found in pregnant women with pre-existing hemorrhoids. Since hemorrhoids and its symptoms will gradually resolve after giving birth, the primary goal of treatment is to relief acute symptoms related to hemorrhoids – mostly by means of dietary and lifestyle modification. Kegel exercises, lying on left side, and avoidance of constipation could reduce the episode and severity of bleeding and prolapse. Fiber supplement, stool softener and mild laxatives are generally safe for pregnant women. Topical medication or oral phlebotonics may be used with special caution because the strong evidence of their safety and efficacy in pregnancy is lacking. In case of massive bleeding, anal packing could be a simple and useful maneuver. Hemorrhoidectomy is reserved in strangulated or extensively thrombosed hemorrhoids, and hemorrhoids with intractable bleeding.

Hemorrhoids in immunocompromised patients

In general any intervention or operation should be avoided, or performed with a careful consideration in immunocompromised patients because of an increases risk of anorectal sepsis and poor tissue healing in such cases[42]. A conservative measure is the mainstay for the treatment of hemorrhoids in this group of patients. If required, injection sclerotherapy appeared to be a better and safer alternative to banding and hemorrhoidectomy for treating bleeding hemorrhoids[43,44]. Antibiotic prophylaxis is always given before performing any intervention, even a minor office-based procedure, due to the possibility of bacteremia.

Hemorrhoids in patients with cirrhosis or portal hypertension

A clinician must differentiate bleeding hemorrhoids form bleeding anorectal varices because the latter can be managed by suture ligation along the course of varices, transjugular intrahepatic portosystemic shunt, or pharmacological treatment of portal hypertension[1]. Since a majority of bleeding hemorrhoids in such patients is not life threatening, conservative measure with the correction of any coagulopathy is a preferential initial approach. Of note, rubber band ligation is generally contraindicated in patients with advanced cirrhosis due to the risk of profound secondary bleeding following the procedure. Injection sclerotherapy is an effective and safe procedure for treating bleeding hemorrhoids in this situation. In a refractory case, suture ligation at the bleeder is advised. Hemorrhoidectomy is indicated when bleeding hemorrhoids are refractory to other approaches.

Hemorrhoids in patients having anticoagulant or antiplatelet drugs

Anticoagulant or antiplatelet drugs may promote anorectal bleeding in patients with hemorrhoids and increase risk of bleeding after banding or surgery[45]. Unless the bleeding is persistent or profound, the discontinuity of antithrombotic drugs may be unnecessary because most of the bleeding episodes are self-limited and stop spontaneously. Conservative measure is therefore the mainstay treatment in these patients. Injection sclerotherapy is a preferential treatment for bleeding low-graded hemorrhoids refractory to medical treatment. Rubber band ligation is not recommended in patients with the current use of anticoagulant or antiplatelet drugs due to the risk of secondary bleeding. If banding or any form of surgery for hemorrhoids is scheduled, the cessation of anticoagulant or antiplatelet drugs about 5-7 d before and after the procedure is suggested[46].

FUTURE PERSPECTIVES IN THE TREATMENT OF HEMORRHOIDS

To date, it is obvious that, apart from oral flavonoids-based phlebotonic drugs, currently available medication for hemorrhoids has no or limited beneficial effects on bleeding and prolapsing[19]. Since emerging evidence has suggested that perivascular inflammation, dysregulation of the vascular tone and vascular hyperplasia could play an important role in the development of hemorrhoids[2], the microcirculatory system of hemorrhoid tissue could be a potential and robust target for medical treatment. The combinations of vasoconstrictive and venoconstrictive agents, with or without anti-inflammatory drugs, might be a new pharmacological approach for hemorrhoids.

If an intervention, either office-based procedure or surgery – is indicated, evidence-based approaches must be exercised. Day-case operation or ambulatory surgery should be fully developed together with an effective program for peri-operative care[30]. Despite advances in office-based procedures and better surgical approaches, post-procedural pain and disease recurrence remain the most challenging problems in the treatment of hemorrhoids. Consequently, future researches and novel management of hemorrhoids may focus on how to minimize pain following a procedure and how to prevent recurrent hemorrhoids. Meanwhile, long-term results of newly or recently developed interventions are definitely required.

In conclusion, the better understanding of the pathophysiology of hemorrhoids would prompt the development of effective treatments for hemorrhoids. Preventive measures, by means of dietary and lifestyle modification, may be the best treatment of hemorrhoids. Once hemorrhoids develop, its treatment options mainly depend on the type and severity of hemorrhoids, patient’s preference and the expertise of physicians. Post-procedural pain and disease recurrence remain the most challenging problems in the treatment of hemorrhoids.

Footnotes

Conflict-of-interest statement: The author declare no conflict of interest

Supported by Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Peer-review started: January 27, 2015

First decision: April 14, 2015

Article in press: July 3, 2015

P- Reviewer: Li W, Peng JS, Rutegard J S- Editor: Yu J L- Editor: A E- Editor: Liu XM

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• Claudia Hammond
• BBC Future

November 23, 2015

Photo author, Thinkstock

Photo caption,

People with hemorrhoids may experience discomfort while sitting on a hard surface

Little is good of this stereotype, but there is a lot of information on how to avoid this problem, the correspondent assures

BBC Future .

If you are a sensitive person, you might be better off reading something else. I will understand you.

But let no one say that in this heading (“Medical Myths”) they are embarrassed to talk about inconvenient or unpleasant things when it is necessary to debunk another myth.

An example of our omnivorousness is this material devoted to folk ideas about hemorrhoids.

Two things can be said with certainty about this problem.

First, it is surprisingly widespread: as many as 50% of people have had this disease at least once in their life.

Second, the notion that sitting on a cold (and often damp) surface is the cause of hemorrhoids is far from the truth on closer inspection.

What is Hemorrhoids?

Before we turn to the study of the available data, it will be useful to explain what hemorrhoids are.

Hemorrhoids are itchy, bumpy nodules that form from the choroid plexuses located in the anus.Sometimes they feel like soft balls to the touch – some even compare them to a small bunch of grapes.

People with hemorrhoids may experience discomfort when sitting on hard surfaces – perhaps this is the reason for the myth about the dangers of exposure to cold.

But given that cold compresses are one way to relieve pain, especially when blood clots develop in blood vessels, sitting on a cold one can be beneficial.

The relationship between temperature and the development of hemorrhoids has hardly been studied.

However, in a 2009 study in Germany, sitting on a cold surface was considered one of the many factors that can influence the occurrence of this condition.

Scientists compared two groups of people: some experienced pain associated with prolapse and compaction of hemorrhoids, others did not.

Experiments ranging from lifting weights to coughing, sneezing, eating spicy foods and using wet wipes for intimate hygiene have shown no influence of any of the factors studied (even sitting on cold surfaces) on the likelihood of developing hemorrhoids.

(Research materials in English posted

here, but keep in mind that they contain relevant, rather intimidating photographs).

Although hemorrhoids have nothing to do with sitting on cold or hot surfaces – and apparently with no other factor studied by German scientists, at least one thing is clear.

More specifically, why this particular part of the body is affected by such a problem.

Weakness

Physician Ann Robinson explains: “It’s just one of the weaknesses of the body.”The reason is that three different venous systems are connected in the anus.

Slight swelling of these veins can be beneficial as it promotes expansion of the corpora cavernosa and prevents stool incontinence.

However, excessive swelling leads to the bulging of the veins into the anus, which causes discomfort and pain.

Bleeding is also possible. If they occur, it is necessary to undergo a medical examination, as bleeding can also be symptoms of bowel cancer.

Anything that causes blood flow to the pelvic organs (eg pregnancy) complicates the course of hemorrhoids. Constipation puts pressure on the veins and forces the person to push so hard that the hemorrhoids can fall out and cause pain, including severe pain.

But it’s not all bad. There is information on how to prevent this condition from occurring.

German scientists have found that those who often take a shower or bath develop hemorrhoids less often, and those who push hard during bowel movements, on the contrary, are at increased risk.

For the prevention of hemorrhoids, everything that prevents constipation is useful – foods high in fiber (vegetables, grains and nuts), exercise to maintain a normal weight and drink plenty of fluids.

In addition, it is important not to restrain the urge, but to go straight to the toilet. By the way, I hope you are not reading this article while sitting on the toilet.

Research shows that people who read in the toilet spend more time there than necessary and, as a result, push unnecessarily.

And the task of this section is to tell about diseases, not provoke them.

Limitation of Liability. All information contained in this article is provided for general information only and should not be considered as an alternative to the advice of your healthcare professional or other healthcare professional. The BBC is not responsible for the information posted on external sites linked to in this article and does not endorse any commercial products or services mentioned or recommended on any of these sites.If you have any health problems, contact your physician immediately.

There is nothing terrible in hemorrhoids!

Hemorrhoids in a certain sense can be called a unique disease. Due to its location in the anus, discussing this disease with other people, even with a doctor, is not easy for most people. As a result, there are a lot of rumors about hemorrhoids that have nothing to do with reality.

We asked an oncologist, proctologist and surgeon, a board member of the Russian Society of Endoscopic Surgeons, a member of the International Committee of the American Society of Colorectal Surgeons, a member of the Society of American gastrointestinal and endoscopic surgeons, head of the International School of Practical Surgery, head of the GMS Clinic surgery center, health advisor to the head of the Republic of Kalmykia Badmu Nikolaevich Bashankaev.

– Today we would like to discuss with you such a problem as hemorrhoids. There is evidence that 70–80% of people develop hemorrhoids during their lifetime, although no more than 10–15% seek medical help. How accurate are these numbers? What are the causes of hemorrhoids?

– In the US, it is believed that about 4-10% of the population suffers from some form of hemorrhoids. In Russia, sometimes there is evidence that 80% of our people suffer from hemorrhoids. Hearing such numbers, I keep repeating a standard joke: maybe it is “mental hemorrhoids”, “hemorrhoids of thoughtfulness and reflection”? It happens like this: a person comes in, and it is clear that he has “hemorrhoids” in life, and he does not have physical hemorrhoids, but he does have a mental one.So the data that 80% of the population suffers from hemorrhoids does not correspond to the true incidence. Although, of course, if we are talking about people over 50, then among them the number of people suffering from hemorrhoids is really high. By this age, hemorrhoidal complaints such as blood from the anus, itching near the anus, discomfort, prolapse of nodes, in Europe, have about 30-40% of mature people.

Let me remind you that in the distal part of the rectum (the upper part of the surgical anal canal), covered with the rectal mucosa and not having pain sensitivity, there are internal hemorrhoidal plexuses – internal hemorrhoids, and in its lower part, covered with skin richly innervated by pain receptors, there are external hemorrhoidal plexus – external hemorrhoids.Outer and inner nodes are separated by a “jagged” line. This is the confluence of the mucous membrane and anoderm. The height of the entire anal canal in women is about 2-3 cm, in men – up to 5 cm, therefore, with significant edema, thrombosis or a long history of the disease, external and internal merge (combined form), even surgeons find it difficult to differentiate groups of nodes. In this regard, there are features of the manifestation of hemorrhoidal disease: external hemorrhoids almost always only hurt while it swells or thromboses, and the internal one falls out of the anus and bleeds, causing itching and discomfort.

The causes of hemorrhoids are not fully understood. There are several theories (at least three). One of them, which I like, explains that the basic, fundamental feature of the formation of hemorrhoids is our upright posture, and only then all other factors. The fact is that animals do not have hemorrhoids, because they walk on four legs and their blood does not flow there, there is no combination of straining and hydrostatic pressure. And we, humans, began to walk, and we developed diseases of the spine, veins of the lower extremities and hemorrhoids caused by upright posture.For example, the structure of the anal canal is made up of two muscles (internal and external sphincters) that wrap around each other in order to prevent an inadvertent “fart” or “how.” However, they did it all the same somewhat loosely. Therefore, hemorrhoids are possibly a sealing membrane, like the petals that cover a diaphragm in a camera. When straining, they slip into the anal canal. Accordingly, it is most often believed that a person has hemorrhoids as a result of a combination, in addition to bipedal locomotion, of various predisposing factors, such as heredity, a sedentary lifestyle, pregnancy, chronic constipation, straining, lifting weights, obesity.However, we do not know 100% what causes hemorrhoids. And if you do not know the cause of the disease, then you cannot prevent it 100%.

– How serious a problem is hemorrhoids? What are the symptoms and what tests are needed to confirm the diagnosis? What complications can develop with hemorrhoids?

– In most cases, this is just a decrease in the quality of life: itching, loss of nodes and bleeding bring certain inconveniences.

Much depends on the stage of hemorrhoids.We usually use the English classification for internal hemorrhoids. There are degrees for the outside.

So, for the first stage of internal hemorrhoids, swelling of the nodes and periodic bleeding are characteristic. At the second stage, the nodes increase, dropouts are added (but the nodes adjust on their own). The third stage manifests itself in the same way as the initial ones, however, when the nodes fall out, they no longer adjust themselves and you need to help with your hand or finger. At the fourth stage, there is a constant loss of bleeding nodes, which no longer fit into the anus.

Most often, the first and second stages are found, so usually hemorrhoids are just periodic bleeding, loss of nodes, an uncomfortable sensation, itching. Sometimes in severe cases, when a person does not go to see a doctor for a long time, anemia may develop.

At the same time, I want to say that even in the absence of complaints, people should have a culture of visiting a proctologist, because even if a person is completely healthy and he has no relatives with diseases of the colon.anus, you still need to come to the proctologist for an appointment at 45 years old, discuss with the doctor the need for a colonoscopy and do it. And in the presence of hemorrhoidal complaints, a visit to a proctologist is inevitable, since the main diagnostic method for hemorrhoids is examination and anoscopy: we put a short plastic or iron tube into the anus and at the exit we watch how the nodes fall out. This is not difficult.

– What do you think of the claim that hemorrhoids lead to cancer and are one of the leading causes of death?

– Hemorrhoids reduce the quality of life, but they never develop into cancer.The true hemorrhoid itself cannot transform into cancer. A polyp can grow on it, but cancer never occurs in the arteriovenous hemorrhoidal node itself.

In fact, hemorrhoids are a social disease that primarily changes a person’s mood. It is clear that when a person constantly sees blood in the toilet or on toilet paper, he begins to worry to the point that panic thoughts about death appear. But hemorrhoids cannot be the leading cause of death, if only mentally, in the form of depression.And so, there is nothing terrible in hemorrhoids.

But sometimes hemorrhoids can mask cancer. And even a proctologist can make a mistake and start treating hemorrhoids. But 4 weeks pass, 8 weeks, and the bleeding continues. Thus, one should never relax. It is imperative to do a colonoscopy to be sure, not 99%, but 100% that it is hemorrhoids, and not cancer. One should always remember that cancer of the rectum and colon is the most common type of cancer and always remain alert about this disease.

– How to treat hemorrhoids and is it possible to slow down the development of already existing hemorrhoids? When is conservative treatment of hemorrhoids possible, and when do you have to talk about surgery?

– The first thing to start treating hemorrhoids is to trust your doctor. Each doctor has his own vision of the patient, and if you constantly move from one doctor to another, then each of them will give their recommendations, which will reduce your chances of treatment success.

Sound and informed treatment is very well described in all coloproctological guidelines in the world. It consists in a banal change in stool quality, elimination of constipation, normalization of the diet, including increasing the amount of dietary fiber in the diet, drinking plenty of fluids, limiting alcohol, and justifying the use of drugs in acute situations. For example, if internal hemorrhoids are bleeding, then we suggest for the treatment of suppositories so that the drug gets into the anal canal.If the external node swells, then it is more correct to use only ointments or creams.

If conservative therapy does not help, then you need to think about the operation. But this is after 4-12 weeks of preparatory treatment, and not immediately at the reception with an anoscope in the patient’s anus. There is no need to rush into this matter. I very rarely say right away during the initial examination that an operation is needed. There must be a good reason for immediate surgery.

For a good proctologist out of 100 people who came to him with complaints of hemorrhoids, the operation takes about 5-17%, i.e.That is, on average, only 10% of patients are diagnosed with hemorrhoids, and not 100%. You calmly explain to the patient that they do not die from this, that if he coughs softly, if there is never constipation and he stops performing sharp strength exercises with a barbell, then he will like this quality of life. And you clarify how the patient imagines the operation for hemorrhoids, what are the expectations for recovery, pain syndrome, methods and methods of operations. And after that you tell me that in the first week after the operation he can expect such painful discomfort that he will think that he is pooping with “hedgehogs”, that healing can take 4-6 weeks, and many patients think about whether they need this operation in fact.Yes, we began to use the laser more often, it has excellent results in terms of minor pain syndrome, healing time, but experience has shown that in the first and partially in the third stage, it is associated with a risk of recurrence, which is 5-10 times higher than that of traditional surgery. Milligan to Morgan.

The decision on the operation should be based on the patient’s informed consent: not formal, when they give to sign a piece of paper with the same name and at the same time convince the patient that everything will be fine, but real, when the patient really understands what the benefits of treatment are and what the operation threatens him with. what he risks and what will happen if he agrees or rejects it.

– What operations are performed for hemorrhoids? Tell us about the possibilities of minimally invasive treatment of hemorrhoids?

– There are a huge number of operations for hemorrhoids, and each of the techniques is needed for different situations. There are no two identical hemorrhoids, and each patient needs to be approached individually.

The basic idea with internal hemorrhoids is that we need to somehow control the leg that feeds the hemorrhoidal node, through which blood flows to the enlarged node.Therefore, the most common and, probably, the most radical operation is the Milligan-Morgan operation, during which we excise the complex of both external and internal nodes. As a result of this operation, 2-4 significant wounds remain in the anus, but in advanced cases this may be the only way out. In short, the Milligan-Morgan operation is painful for the patient, but it allows even difficult cases to be cured and guarantees almost complete absence of major relapses.

At the initial stages of the disease, outpatient ligation and sclerotherapy are widely used.These procedures are very minimally invasive and are performed in the proctologist’s office. In fact, the operations look like this: the patient came, lay down on a chair, he underwent a procedure that did not require anesthesia, and after five to twenty minutes he went home. But such procedures are applicable no later than 1–2 stages. In the third stage, the risk of disease recurrence or failure is high.

There are also laser surgeries for hemorrhoids. Their peculiarity lies in the fact that the volume, success and results of such an operation to a certain extent depend on the equipment used and the selection of the right cases.Everyone can’t make a laser. And here I want to boast a little that I have an ultra-modern laser in my clinic and not one for such operations. There are approbation models, there are only two or three such lasers in Russia.

Also, many clinics both in Russia and abroad offer to carry out dearterization of hemorrhoids for hemorrhoids (HAL-RAR method). It allows to carry out surgical intervention for hemorrhoids quickly and painlessly, however, the results of such an operation are highly dependent on the surgeon and often the percentage of relapses in HAL-RAR reaches 30-50%.

Longo’s operation also belongs to the previously popular methods of surgery for hemorrhoids. The Italian professor Antonio Longo, our great friend, in 1993 proposed a new method of radical surgery, which was called hemorrhoidopexy. In Russia, as in the rest of the world, there was a certain enthusiasm and love for the procedure, but now these are single operations. The reasons are standard: sophisticated complications and an incredible rate of recurrence of complaints.

However, as always, the choice of a doctor, his qualifications and experience are the most important components of success in any operation, along with the patient’s confidence in his attending physician and the patient’s readiness to strictly follow the recommendations received.If all these requirements are met, then it will not be difficult to cure hemorrhoids and it will not affect your lifestyle, plans, thoughts and mood in any way.

I am very impressed with the Japanese national guidelines for the treatment of hemorrhoids from 2017, which mainly focuses on lifestyle changes (Everyday Lifestyle Guidance), which include:

• in the limitation of a long sitting position,
• limiting work in cold conditions,
• restriction of straining during bowel movements,
• careful selection of food and drink,
• moderate physical activity,
• reducing emotional stress.

Good luck, dear readers!

Source: DNAhealth.ru
90 011 90 000 causes, symptoms and current treatment methods

What are hemorrhoids?

Hemorrhoids is a disease resulting from hyperplasia of the cavernous tissue of the submucosal layer of the end section of the rectum and stagnation of blood in it due to impaired outflow through the veins.

Hemorrhoids are equally common in middle-aged and elderly men and women.

The prevalence is approximately 150 cases per 1000 adult population. Among proctological diseases, hemorrhoids account for 40%.

The term “hemorrhoids” is translated from Greek as bleeding. It is bleeding, sometimes anal itching and rectal discomfort that can manifest hemorrhoids. Therefore, when these symptoms appear, it is imperative to visit a proctologist. You should be aware that under the mask of hemorrhoids other dangerous diseases can be hidden, which are also manifested by bleeding.In the initial stages of hemorrhoids, the above symptoms appear during heavy physical exertion, with diarrhea and constipation, after a violation of the diet (especially after excessive consumption of alcoholic beverages), sometimes after a bath or taking a hot bath, during pregnancy, etc.

But not all patients have bleeding from the anus during bowel movements is the first symptom of the disease. Often, a violation of the diet, excessive consumption of alcohol or provoking food can immediately lead to an exacerbation of the disease, to inflammation of the hemorrhoids.

Classification and types of hemorrhoids

Distinguish between hemorrhoids acute and chronic . By localization, hemorrhoids are divided into external , internal and combined . According to the mechanism of development, hemorrhoids are hereditary and acquired, primary (which is an independent disease) and secondary (when the expansion of the rectal veins is a concomitant symptom of other diseases).

Chronic hemorrhoids. Periodically, after a bowel movement, there are unpleasant sensations in the anus: a feeling of discomfort, slight itching, high humidity.In the future, blood may be released during bowel movements.

Stages of chronic hemorrhoids:

• 1st stage: regular bleeding during bowel movements without prolapse of hemorrhoids
• 2nd stage: periodic prolapse of hemorrhoids during exercise (during bowel movements or heavy lifting) and their spontaneous reduction
• Stage 3: Regular prolapse of hemorrhoids, which patients correct manually
• 4th stage: constant loss of nodes, even with a slight load, and it turns out to be impossible to correct them

Acute hemorrhoids (anorectal thrombosis) – thrombosis of internal and / or external hemorrhoids.

The acute form of hemorrhoids is divided into three degrees:

• 1st degree: thrombosis of hemorrhoids without inflammation.
• 2nd degree: thrombosis complicated by inflammation of the hemorrhoids.
• 3rd degree: thrombosis of hemorrhoids, complicated by inflammation of the subcutaneous tissue and perianal skin.

Hemorrhoid Treatment

Conservative (drug) treatment of hemorrhoids is mainly aimed at combating its exacerbations.Therefore, it should be understood that due to the chronic nature of the disease, any conservative treatment is temporary. A sedentary lifestyle, dietary errors and excessive physical activity lead to another exacerbation of the disease.

Today, minimally invasive methods of treating hemorrhoids in the early stages, used on an outpatient basis, are widely used in medical practice. These include infrared photocoagulation, sclerotherapy, ligation of hemorrhoids with latex rings, ligation of hemorrhoids under the control of ultrasound dopplerometry, and others.

In the later stages of the disease, an operation (hemorrhoidectomy) is performed, aimed at radical removal of hemorrhoids.

• At stage 1 hemorrhoids are indicated: conservative therapy, infrared photocoagulation, sclerotherapy.
• For hemorrhoids of the 2nd stage, the following are indicated: conservative therapy, infrared photocoagulation, sclerotherapy, ligation with latex rings, suture ligation, combined methods.
• In stage 3 hemorrhoids, the following are indicated: ligation with latex rings, transanal mucosal resection using the Longo method, combined methods, surgical treatment (hemorrhoidectomy).
• Surgical treatment (hemorrhoidectomy) is indicated for stage 4 hemorrhoids.

You should be aware that under the mask of hemorrhoids other dangerous diseases can be hidden, including rectal cancer. In some cases, attributing the symptoms of rectal cancer to hemorrhoids, a person learns too late about the true diagnosis. Do not self-diagnose and self-medicate, do not save on your health. Consult your doctor in time for the correct diagnosis.

At the consultation, the doctor examines the area of ​​the anus, perineum, sacrum and coccyx, performs a digital examination of the rectum (it allows you to determine the condition of the muscle that compresses the anus, to identify the formations located in the lower parts of the rectum). Instrumental diagnostic methods are performed: anoscopy (examination of the end section of the rectum – about 5 cm), rectoscopy or rectosigmoscopy (examination of the rectum and sigmoid colon to a depth of 15 to 30 cm).Anoscopy and rectosigmoscopy are absolutely painless, the patient only feels slight discomfort in the rectum and in the lower abdomen. All these four stages are included in the standard complex of examination of a patient by a proctologist.

Timely examination by an experienced proctologist will relieve you of doubts and allow you to choose an effective and gentle treatment method.

Our medical center has all the necessary equipment for the diagnosis and treatment of proctological diseases, the most comfortable conditions for patients have been created.Here you can get highly qualified advice and assistance at affordable prices.

Contact our medical center! We will be happy to help you!

Doctor-proctologist, candidate of medical sciences, associate professor V.A. Ginyuk

Hemorrhoid treatment without surgery using latex ligation

Latex ligation of the hemorrhoid is a unique treatment of hemorrhoids without surgery, which is offered by “Es Class Clinic Ulyanovsk”.The method is modern, fast and highly effective. The manipulation is carried out by experienced proctologists in a clinic. It only takes 10 minutes.

The method is used to treat hemorrhoids in the most advanced stages. Moreover, he:

• painless:
• has practically no contraindications;
• has a fast recovery period;
• is non-traumatic, does not cause any blood loss.

What is the essence of the method

Latex ligation uses rubber rings that are put on the knot using a special device.The ring squeezes the vessels through which blood enters the node. Without nutrition, it dries up and dies, after which it separates from the walls of the rectum and falls out through the anus along with a latex ring. A small scar remains at the site of the node, which does not disrupt the natural process of defecation.

Complete dying off of the nodes occurs 1-3 days after the procedure, the ring is rejected for 7-14 days. And then the ligation with latex rings can be repeated, for example, if there are multiple knots or the knot is very large.

Nodes are removed strictly one at a time. This reduces the likelihood of developing pain and postoperative complications. In order to get rid of a large formation guaranteed and the first time, 2 rings are applied to it. It is this break between procedures that is recommended for the respective patients.

Method variations

There are two ways to ligate hemorrhoids: mechanical and vacuum.

• For mechanical ligation, the assembly is grasped by forceps inserted through the anoscope. All manipulations are carried out manually, therefore they require more stress and time for the doctor and can be uncomfortable for the patient.
• A special device is used for vacuum ligation. It is inserted into the rectum, after which the doctor creates negative pressure at the tip. The knot itself is sucked into the ligator, and a latex ring is instantly put on it without damaging nearby tissues.After that, the specialist equalizes the pressure and takes out the device. It is very important that the ring is put on strictly on the knot, this guarantees its rapid death and the integrity of the rectum. It is this result that can be achieved using a vacuum device.

Es Class Clinic Ulyanovsk uses the second method, as it is less traumatic, convenient and fast.

Are there any contraindications?

The method has only one direct contraindication – a blood disease in which its coagulability is impaired.Ligation should also be avoided when hemorrhoids are located outside the anus. It is ineffective in the initial stages of hemorrhoids, but there are easier ways to treat them.

The doctor may suggest to postpone the ligation even if:

• there is an acute inflammatory process in the rectum;
• general inflammation, such as an infectious disease, is present;
• has open, unhealed anal fissures.

During the appointment, the specialists of “Es Class Clinic” will assess the need for the procedure, answer questions of interest and subsequently carry out the manipulation as delicately and efficiently as possible. The price for the procedure is low, it is available to everyone. Recording is carried out online and by the specified phone numbers.

90,000 reasons, complaints, diagnostics and treatment methods on the website of the clinic “Alfa-Health Center”

Inflammation of the hemorrhoids formed as a result of the expansion of the veins of the anus, the prolapse of the nodes outward.Symptoms are sharp pain, which increases with bowel movements, periodic bleeding.

Most people over 50 suffer from hemorrhoids. The three main clusters of vascular tissue are normally located in the submucosal layer of the anal canal. These plexuses can fill with blood to protect the anal canal during bowel movements. With age and with the appearance of various concomitant diseases, the supporting muscle plate of the submucosal layer is destroyed, which leads to stretching of the veins and the appearance of nodes.These nodes are often thrombosed and ulcerated. Sedentary work and food poor in fiber predispose to constipation, which is manifested by too much stretching of the intestinal wall during bowel movements; from this, hemorrhoids protrude more strongly into the lumen of the intestine.

External and internal hemorrhoids differ in the location of the nodes relative to the rectal-anal line, although the external and internal nodes can merge into a single conglomerate. There are four stages of hemorrhoids. At the first stage, the nodes protrude into the anal canal, but do not fall out.At the second stage, the nodes fall out, but they adjust on their own. On the third, the knots that have fallen out have to be adjusted by hand, on the fourth, the knots that have fallen out cannot be adjusted. Staging is important for the choice of treatment.

External hemorrhoids

External hemorrhoids are manifested by the secretion of mucus and a small amount of blood from the anus. Mucus begins to flow when the knot interferes with the closure of the anus. In this case, anal itching may occur. External hemorrhoids are prone to thrombosis.This is an extremely painful condition, and thrombosis often develops after constipation.

As a rule, with external hemorrhoids, it is enough to improve the consistency and increase the volume of feces with the help of a diet. In addition, hygiene rules have been developed. For example, the patient is advised to take a sitz bath, not to sit for a long time and not to push during bowel movements. In acute thrombosis within 2-3 days from the onset of the disease, hemorrhoids can be excised under local anesthesia.

General recommendations for patients with hemorrhoids are as follows:

• Drink plenty of fluids.Drink at least 6-8 glasses of water or juice daily; you should not drink tea, coffee and carbonated drinks
• Eat fruits and vegetables at least 4-5 times a day
• Take fiber (such as plantain seed) 1 tablespoon, diluted in a glass of water, 1-2 times a day. Take sodium docusate 50-100 mg 1-2 times a day.
• Take a sitz or regular bath with warm water twice a day. Do not lather the perianal area as this may irritate.
• After a bowel movement, do not rub or scratch the perianal area, but gently blot it with toilet paper. After a sitz bath or bowel movement, apply a cotton swab to your anus. Change cotton wool after bath and bowel movement
• Don’t sit on the toilet; do not read in the restroom
• Avoid or minimize the use of narcotic analgesics (such as codeine or oxycodone / paracetamol), as these drugs can cause constipation
• Don’t sit for long periods.Lie down frequently with a pillow under your thighs to raise the perianal region

Internal hemorrhoids

As a rule, internal hemorrhoids are not as painful as external ones. Internal hemorrhoids are manifested by bleeding and prolapse of nodes. Just as with external hemorrhoids, in the first and second stages of the disease, it is usually enough to eat right, regularly empty the intestines and observe hygiene rules. If this does not help, more sophisticated treatments are used.

Surgical treatment is required in less than 10% of patients with clinical manifestations of hemorrhoids. For internal hemorrhoids of the first, second and sometimes third stages, cryotherapy, diathermocoagulation, laser coagulation, infrared photocoagulation, sclerotherapy and ligation with rubber rings are used; none of the methods has clear advantages.

Hemorrhoidectomy is performed for hemorrhoids of the third and fourth stages, with the ineffectiveness of conservative treatment at earlier stages and with mixed hemorrhoids (if there are both external and internal nodes).The operation can be performed on an outpatient basis.

90,000 Treatment of hemorrhoids free of charge under the compulsory medical insurance policy in Moscow – MSZ.RF

It is not customary to talk about hemorrhoids, although every second person over 50 suffers from this chronic disease. Moreover, in men it occurs three times more often than in women. Hemorrhoids not only deliver physical pain, but have the same symptoms as some bowel cancers. Only a proctologist is able to carry out differential diagnostics, a visit to whom should never be postponed “until Monday.”

What is Hemorrhoids?

It is often said that hemorrhoids are varicose veins of the intestines. In fact, the hemorrhoidal area is called the lower rectum, where special cavernous (cavernous) bodies with a large number of small veins are located under the mucous membrane. Nature provides that their walls are supported by connective tissue, but if it weakened, blood flow increases, and overcrowded bodies (or hemorrhoids) protrude through the anal passage.If they are injured by passing feces or linen, then bleeding begins, which people usually say more simply: “hemorrhoids bleeds.”

It is generally accepted that all diseases are caused by nerves. Hemorrhoids in this case are an exception to the rule. Stress does not directly affect the occurrence of hemorrhoids. However, it should be borne in mind that various experiences can cause chronic constipation, and it already provokes hemorrhoids.

Causes of the disease

There is a myth that hemorrhoids are the lot of truck drivers who are forced to sit in one position at the wheel for a long time.This is only partly true. The question “Why does hemorrhoids arise in some people, and bypasses others?” is still not fully understood. Modern science does not name the causes of hemorrhoids, but rather the factors that increase the risk of the onset of the disease. In addition to a sedentary lifestyle, these include: hard physical work, obesity, unbalanced diet and hereditary predisposition.

Hemorrhoids occur not only in adults, but also in children: either it is a congenital weakness of the vessels of the rectal canal, or the parents use the wrong tactics to wean the baby from diapers (when the child is forced to sit on the potty for a long time in order to “seize the moment”), or it is rude violation of the diet in adolescents, leading to chronic constipation.

Main symptoms

Most often, patients begin to suspect they have hemorrhoids by a “bump” that they feel on their own while taking a bath or standing in the shower. The most common signs of hemorrhoids are: a burning sensation in the anus, itching, a feeling of incomplete emptying after a bowel movement.

Symptoms of hemorrhoids can vary, depending on the severity of the disease and its type. For example, the main symptoms of internal hemorrhoids – pain and scarlet blood remaining on top of the feces, indicate hemorrhoids 3-4 stages, in which conservative treatment is no longer possible.Cracks in hemorrhoids are associated with a violation of the elasticity of the rectum – in places of thinning, it simply breaks.

The patient cannot independently assess the severity of the condition based on the available signs of hemorrhoids. Because bleeding can speak not only of a hemorrhoid symptom, but also of other serious diseases. Timely differential diagnosis in this case is extremely important. You need to go to the proctologist on a regular basis: after reaching 40 years of age – once every two years.

Types of hemorrhoids

There are 3 types of hemorrhoids: external, internal and combined.With external (external) hemorrhoids, the patient himself can see the enlarged hemorrhoids with the help of a mirror, since they are located next to the anus.
The diagnosis of “internal hemorrhoids” can only be made by a doctor, conducting an instrumental examination, because the nodes are not visible to the naked eye.

With the combined form of hemorrhoids, the nodes are located both in the rectal cavity and outside it.

Depending on the course of the disease, in proctology it is also customary to divide hemorrhoids into acute and chronic.

In acute hemorrhoids, the symptoms grow rapidly, and the inflammatory process rapidly affects the tissues adjacent to the nodes, causing their necrosis. The patient suffers from pain and blood loss.

Chronic hemorrhoids are characterized by slow development, in which the nodes fall out, then they are reduced, and during the period of “lull” they may not declare themselves in any way.

Stage 4 hemorrhoids

• In medicine, 4 stages (degrees) of hemorrhoids are described.
• 1.First (initial hemorrhoids). There are practically no symptoms or they arise periodically after some provoking factor (lifting a load, constipation, etc.). The patient can only complain of mild discomfort during bowel movements.
• 2. Second. The nodes are enlarged, occasionally bleed slightly, fall out of the anus, but adjust on their own.
• 3. Third. Knots fall out regularly and require manual adjustment. The patient suffers from severe itching after bowel movement and profuse bleeding.
• 4. Fourth. Exacerbation of hemorrhoids occurs regularly: the nodes fall out at the slightest load (for example, during a cough) and the patient himself can no longer correct them. From profuse blood loss, the amount of hemoglobin in the blood falls.

How to cure hemorrhoids?

How can hemorrhoids be cured? To answer this question, you need to clearly understand which doctor treats hemorrhoids, because often patients spend precious time referring to doctors of other specialties.Remember: you need a coloproctologist (from the Latin word “proctos” – anus).

At stages 1–2, it is quite possible to cure hemorrhoids without surgery (*). Conservative treatment includes the use of drugs for hemorrhoids for external and internal use at the same time. These can be suppositories based on sea buckthorn oil, various ointments that reduce swelling and eliminate soreness, and Detralex capsules (a phlebotropic drug that protects the mucous membrane and increases venous tone).

For the treatment of internal and external hemorrhoids at 2-3 stages, some drugs will already be insufficient. Therefore, various minimally invasive techniques are used, due to which injuries during surgery are reduced and the time spent in the hospital is shortened.

Treatment methods

Removal of hemorrhoids with laser

Infrared radiation is used to cauterize blood vessels. Does not require anesthesia.

Desarterization

Effective if there is one large node.The purpose of the operation is to stop the blood flow in the node. Passes under the control of Doppler ultrasonography.

Thrombectomy

It consists in the fact that a thrombus is removed from the cavity of the node. Does not require hospitalization.

Sclerotherapy

A sclerosant is injected into the lumen of a hemorrhoidal vessel – a substance that causes “sticking” of its walls, after which the node disappears.

Ligation

More often used in elderly patients suffering from various complications of hemorrhoids. A latex ring is applied to the knot, after which it does not receive blood supply and dies off.

Cryotherapy

The node is first frozen, and after it dies off, connective tissue appears at the site of the wound over time. The operation requires local anesthesia. Not included in the basic compulsory medical insurance program!

Unfortunately, all rectal surgeries are painful, this is a sensitive area. We always strive to reduce pain after surgery. They usually go away under spinal anesthesia. If in the morning I operated on a patient, in the afternoon he still has no pain.Are pain relievers needed for hemorrhoids? Necessarily. I say this: as soon as you feel your legs, immediately to the oncoming injection, you do not have to wait until it hurts seriously! And nothing, in the end the patient himself comes to the dressing.

* Please note that the decision to choose a particular method of treatment is made by the doctor, depending on the patient’s individual indications and contraindications.

Should you perform an operation?

A radical operation to remove hemorrhoids is called “hemorrhoidectomy”.Proctologists resort to it as a last resort, when less traumatic techniques are no longer effective (at stages 3-4 of the disease). The main indications for hemorrhoidectomy are frequent thrombosis (up to 4 times a year), massive bleeding causing anemia, prolapse of nodes after defecation with inability to reposition.

The essence of the operation is that hemorrhoids are excised, a special medical thread (ligature) is applied at their base and the edges of the wound are sutured.

• Hemorrhoids after surgery requires strict adherence to the doctor’s instructions:
• – minimum physical activity;
• – exclude heavy lifting;
• – do not take hot baths.

Hemorrhoids after childbirth – what to do?

A common occurrence and hemorrhoids in pregnant women. Its appearance is due to physiology: the growing uterus puts pressure on the veins of the corpora cavernosa, thereby provoking the appearance of hemorrhoids. Many expectant mothers are tormented by the question: “How to treat hemorrhoids during pregnancy and after childbirth with breastfeeding?” It is definitely not worth enduring pain and discomfort. In these cases, conservative therapy (ointments, rectal suppositories) is prescribed under the supervision of a gynecologist so that the composition of the drugs could not cause potential harm to the fetus.

Effortless Prevention

If the disease is started, then most of the surgical interventions will be extremely painful, and the rehabilitation period will require time and patience from the patient.Not to mention the fact that no one is safe from recurrence of hemorrhoids if you don’t change your lifestyle. So isn’t it easier not to bring your body to such a deplorable state?

Prevention of hemorrhoids does not require any super-efforts and is quite real if you approach your own health consciously. It is necessary to prevent the appearance of constipation, for which you need to eat more vegetables, fruits and coarse fiber. And also move more and drink plenty of regular water.

When they ask me for recommendations on the prevention of hemorrhoids, I immediately ask the patient: “How much do you weigh?” Let’s say 60 kg.Multiply by three. It turns out that he needs to drink 1 liter of 800 grams per day. And nothing less. Compliance with the drinking regime is the prevention of constipation, and, consequently, hemorrhoids.

Material prepared jointly with the expert: Eteri Enverovna Bolkvadze,
MD, head of the department of coloproctology, GKB №15 named after. O. M. Filatova

Source: information project
“Moscow – the capital of health”

Contraindications to donation – Blood Service

Almost any healthy person can become a donor if he is over 18 years old, has no contraindications to donation,
and its weight is more than 50 kg.

On the other hand, only a Man with a capital letter can become a donor of blood and its components. The person who is ready
get up early, take your time to save someone’s life .

CONTRAINDICATIONS

At each visit to a blood service facility, a potential donor undergoes a free medical examination, which
includes an appointment with a transfusion doctor and a preliminary laboratory study.

At the same time, there are a number of contraindications to donation: permanent, that is, independent of the duration of the disease and the results
treatment, and temporary – acting only for a certain period.

Permanent contraindications are
the presence of such serious diseases as infectious and parasitic diseases, oncological diseases, diseases
blood, as well as a number of other conditions.

You may be disappointed that you cannot donate if you have absolute
contraindications.
However, the Blood Service hopes that you will understand our main task – ensuring the safety of components
donated blood for patients.

The presence of contraindications to donation does not mean that you cannot contribute to the development of voluntary
blood donation!
In the section “Volunteers” you can find out how to help
Donor movement. Save lives with Blood Service!

Temporary contraindications have
different time frames depending on the reason. The most common prohibitions are: tattooing, piercing
or acupuncture treatment (120 calendar days), tonsillitis, flu, ARVI (30 calendar days after recovery),
the period of pregnancy and lactation (1 year after childbirth, 90 calendar days after the end of lactation), vaccinations.

List of medical contraindications for donating blood and its components

(according to the Order of the Ministry of Health of the Russian Federation dated October 28, 2020 No. 1166n “On
approval of the procedure for passing a medical examination by donors and a list of medical contraindications
(temporary and permanent) for donating blood and (or) its components and the timing of the withdrawal to which a person is subject to
the presence of temporary medical contraindications, from the donation of blood and (or) its components “)

Permanent medical contraindications

1.Infectious and parasitic diseases:

• disease caused by human immunodeficiency virus (HIV), hepatitis B and C viruses,
• syphilis, congenital or acquired,
• tuberculosis (all forms),
• brucellosis
• typhus,
• tularemia,
• leprosy (Hansen’s disease),
• African trypanosomiasis,
• Chagas disease,
• leishmaniasis,
• toxoplasmosis,
• babesiosis,
• Chronic Q Fever,
• echinococcosis,
• filariasis,
• dracunculiasis,
• Repeated positive test result for markers of immunodeficiency virus disease
  human (HIV infection),
• repeated positive test result for markers of viral hepatitis B and C,
• repeated positive test result for markers of the causative agent of syphilis.

2. Malignant neoplasms.

3. Diseases of the blood, blood-forming organs and certain disorders involving the immune
mechanism.

4. Diseases of the central nervous system (organic disorders).

5. Complete absence of hearing and (or) speech, and (or) sight.

6. Mental and behavioral disorders in a state of exacerbation and (or)
posing a danger to the patient and others.

7. Mental and behavioral disorders caused by the use of psychoactive
substances.

8. Diseases of the circulatory system:

• hypertensive (hypertensive) heart disease II – III degree,
• ischemic heart disease,
• thromboangiitis obliterans,
• nonspecific aortoarteritis,
• phlebitis and thrombophlebitis,
• endocarditis,
• myocarditis,
• heart disease (congenital, acquired).

9. Diseases of the respiratory system:

• bronchial asthma,
• bronchiectasis,
• emphysema.

10. Diseases of the digestive system:

• achilic gastritis,
• chronic liver diseases, including unspecified, toxic liver damage,
• calculous cholecystitis with recurring attacks and symptoms of cholangitis,
• cirrhosis of the liver.

11. Diseases of the genitourinary system in the stage of decompensation:

• diffuse and focal kidney lesions,
• urolithiasis.

12. Diseases of the connective tissue, as well as acute and (or) chronic osteomyelitis.

13. Radiation sickness.

14. Diseases of the endocrine system in the stage of decompensation.

15. Diseases of the eye and its adnexa:

• uveitis,
• irit,
• iridocyclitis,
• chorioretinal inflammation,
• trachoma,
• myopia 6 diopters or more.

16. Diseases of the skin and subcutaneous tissue:

• psoriasis,
• erythema,
• eczema,
• pyoderma,
• sycosis,
• pemphigus (pemphigus),
• dermatophytosis,
• furunculosis.

17. Surgical interventions (resection, amputation, removal of an organ (stomach, kidney,
spleen, ovaries, uterus, etc.)), organ and tissue transplantation, resulting in permanent disability
(I and II disability groups), organ xenotransplantation.

18. Persistent disability (I and II group of disability).

19. Female donor for donation of 2 units of erythrocyte mass or suspension obtained
by apheresis method.

20. Persons with repeated non-specific reactions to markers of immunodeficiency viruses
human, hepatitis B and C and the causative agent of syphilis.

21. Persons with re-identified alloimmune antibodies to erythrocyte antigens (for
excluding plasma donors for the production of drugs).

22. Persons with re-identified anti-A1 extraagglutinins (excluding plasma donors
for the production of medicines).

Temporary contraindications

Items

Deadline for withdrawal from donation

Body weight less than 50 kg

Until reaching a body weight of 50 kg

Age under 20 years
for donation of 2 units of red blood cell mass or suspension,
obtained by apheresis

Until the age of 20

Body weight less than 70 kg
for donation of 2 units of erythrocyte mass or suspension,
obtained by apheresis

Until reaching a body weight of 70 kg

Hemoglobin less than 140 g / l
for donation of 2 units of erythrocyte mass or suspension,
obtained by apheresis

Until reaching a hemoglobin level of 140 g / l

Body temperature above 37 ° C

Until body temperature returns to normal (37 ° C and below)

Pulse – less than 55 beats per minute and more than 95 beats per minute

Until the heart rate returns from 55 to 95 beats per minute

Blood pressure:
systolic less than 90 mm Hg.Art. and more than 149 mm Hg. Art .;
diastolic – less than 60 mm Hg. Art. and more than 89 mm Hg. Art.

Before normalization
systolic pressure: 90 – 149 mm Hg. Art .;
diastolic pressure: 60 – 89 mm Hg. Art.

Body mass index

Less than 18.5 and more 40

Disagreement in the results of the study of blood group AB0, Rh-belonging, antigens C,
c, E, e, K with research results from previous donation

Prior to performing a confirmatory study

Transfusion of blood and (or) its components

120 calendar days from the date of transfusion

Primary detection in a blood sample of a donor of alloimmune antibodies to erythrocyte antigens

Until confirmation of the absence of alloimmune antibodies to antigens in the donor’s blood sample
erythrocytes no earlier than 180 calendar days after the initial detection

Surgery, including artificial termination of pregnancy

120 calendar days from the date of surgery

Medical and cosmetic procedures in violation of the skin (tattoos, piercings,
acupuncture and other)

120 calendar days from the end of the procedure

Until the absence of markers of viral hepatitis B and / or viral hepatitis C is confirmed, and
(or) a disease caused by the human immunodeficiency virus (HIV infection), and (or) the causative agent of syphilis, but not
earlier than 120 calendar days after receiving a questionable laboratory test result

120 calendar days after the termination of the last contact

Questionable result for markers of viral hepatitis B and / or viral hepatitis C, and
(or) a disease caused by the human immunodeficiency virus (HIV infection), and (or) the causative agent of syphilis

Until the absence of markers of viral hepatitis B and / or viral hepatitis C is confirmed, and
(or) a disease caused by the human immunodeficiency virus (HIV infection), and (or) the causative agent of syphilis, but not
earlier than 120 calendar days after receiving a questionable laboratory test result

Past infectious diseases:

a history of malaria in the absence of symptoms and in the presence of negative results of immunological
tests

3 years

typhoid fever after recovery and complete clinical examination in the absence of
severe functional disorders

1 year

angina, flu, acute respiratory viral infection

30 calendar days after recovery

Transferred infectious and parasitic diseases not indicated in the list of permanent and
temporary contraindications

120 calendar days after recovery

Acute or chronic inflammatory processes in the acute stage, regardless of
localization

30 calendar days after stopping the acute period

Aggravation of stomach and (or) duodenal ulcers

1 year from the moment of relief of the acute period

Kidney diseases not specified in paragraph 12 of the list of permanent contraindications

1 year from the moment of relief of the acute period

Allergic diseases in the acute stage

60 calendar days after stopping the acute period

Period of pregnancy, lactation

1 year after childbirth,
90 calendar days after the end of lactation

vaccination with inactivated vaccines (including against
tetanus, diphtheria, whooping cough,
paratyphoid fever, cholera, flu), toxoid

10 calendar days after vaccination

vaccination with live vaccines (including against brucellosis, plague, tularemia,
tuberculosis, smallpox, rubella, oral poliomyelitis), administration of tetanus toxoid (with
absence
severe inflammation at the injection site)

30 calendar days after vaccination

vaccination with recombinant vaccines (including against viral hepatitis B,
coronavirus infection)

30 calendar days after vaccination

administration of immunoglobulin against hepatitis B

120 calendar days after vaccination

administration of immunoglobulin against tick-borne encephalitis

120 calendar days after vaccination

rabies vaccination

1 year after vaccination

Taking medications:

antibiotics

14 calendar days after the end of admission

analgesics, anticoagulants, antiplatelet agents (including salicylates)

3 calendar days after the end of admission

Drinking alcohol

48 hours

Deviation of the limits of the composition and biochemical parameters of peripheral blood

Compositional and biochemical limits deviation
indicators
peripheral blood

Indicator

Permissible limits of values ​​of indicators

Hemoglobin:

men (130 g / l and more)

women (120 g / l and more)
Until the permissible limits of the values ​​of indicators are reached, but not earlier than 30 calendar days

130 g / l and more
120 g / l and more

Hematocrit:

men (0.40 or more)

women (0.38 and more)
Until the permissible limits of the values ​​of indicators are reached, but not earlier than 30 calendar days

0.40 and more
0.38 and more

Number of platelets

from 180 x 10 ⁹ / l
Until the permissible limits of the values ​​of indicators are reached, but not earlier than 30 calendar days

Erythrocyte count

men (4.0 x 10 ¹² / L and more)

women (3.8 x 10 ¹² / l and more)
Until the permissible limits of the values ​​of indicators are reached, but not earlier than 30 calendar days

4.0 x 10 ¹² / l and more
3.8 x 10 ¹² / l and more

Leukocyte count

4 x 10 ⁹ / l to 9 x 109 / l
Until the permissible limits of the values ​​of indicators are reached, but not earlier than 30 calendar days

Total protein

from 65 g / l to 85 g / l
Until the permissible limits of the values ​​of indicators are reached, but not earlier than 30 calendar days

Ratio of protein fractions (albumin, globulins)

no deviations from the standard values ​​specified in the instructions for
Reagent Kits and Methods Used
Until the permissible limits of the values ​​of indicators are reached, but not earlier than 30 calendar days

Until the permissible limits of values ​​of indicators are reached, but not earlier than 30 calendar days

Bloodborne diseases – diseases resulting from blood transfusion

Transfusion – blood transfusion

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The modern effective activity of the Blood Service became possible only thanks to the implementation of the main directions of its development.