Diarrhea and Bleeding | Gastroenterologist In New York, NY

Diarrhea and Bleeding in New York, NY

What is Diarrhea and Bleeding?

To evaluate minor rectal bleeding, your doctor may perform a digital rectal examination. In addition, an endoscopic procedure such as anoscopy, flexible sigmoidoscopy or colonoscopy may be recommended.

Minor rectal bleeding refers to the passage of a few drops of bright red (fresh) blood from the rectum, which may appear on the stool, on the toilet paper or in the toilet bowl.

This brochure addresses minor rectal bleeding that occurs from time to time. Continuous passage of significantly greater amounts of blood from the rectum or stools that appear black, tarry or maroon in color can be caused by other diseases that will not be discussed here. Call your doctor immediately if these more serious conditions occur. Because there are several possible causes for minor rectal bleeding, a complete evaluation and early diagnosis by your doctor is very important. Rectal bleeding, whether it is minor or not, can be a symptom of colon cancer, a type of cancer that can be cured if detected early.

What are hemorrhoids?

Hemorrhoids (also called piles) are swollen blood vessels in the anus and rectum that become engorged from increased pressure, similar to what occurs in varicose veins in the legs. Hemorrhoids can either be internal (inside the anus) or external (under the skin around the anus). Hemorrhoids are the most common cause of minor rectal bleeding, and are typically not associated with pain. Bleeding from hemorrhoids is usually associated with bowel movements, or it may also stain the toilet paper with blood. The exact cause of bleeding from hemorrhoids is not known, but it often seems to be related to constipation, diarrhea, sitting or standing for long periods, obesity, heavy lifting and pregnancy. Symptoms from hemorrhoids may run in some families. Hemorrhoids are also more common as we get older. Fortunately, this very common condition does not lead to cancer.

Hemorrhoids and rectal polyps are common causes of minor rectal bleeding.

How are hemorrhoids treated?

Medical treatment of hemorrhoids includes treatment of any underlying constipation, taking warm baths and applying an over-the-counter cream or suppository that may contain hydrocortisone. If medical treatment fails there are a number of ways to reduce the size or eliminate internal hemorrhoids. Each method varies in its success rate, risks and recovery time. Your doctor will discuss these options with you. Rubber band ligation is the most common outpatient procedure for hemorrhoids in the United States. It involves placing rubber bands around the base of an internal hemorrhoid to cut off its blood supply. This causes the hemorrhoid to shrink, and in a few days both the hemorrhoid and the rubber band fall off during a bowel movement. Possible complications include pain, bleeding and infection. After band ligation, your doctor may prescribe medications, including pain medication and stool softeners, before sending you home. Contact your doctor immediately if you notice severe pain, fever or significant rectal bleeding. Laser or infrared coagulation and sclerotherapy (injection of medicine directly into the hemorrhoids) are also office-based treatment procedures, although they are less common. Surgery to remove hemorrhoids may be required in severe cases or if symptoms persist despite rubber band ligation, coagulation or sclerotherapy.

What are anal fissures?

Tears that occur in the lining of the anus are called anal fissures. This condition is most commonly caused by constipation and passing hard stools, although it may also result from diarrhea or inflammation in the anus. In addition to causing bleeding from the rectum, anal fissures may also cause a lot of pain during and immediately after bowel movements. Most fissures are treated successfully with simple remedies such as fiber supplements, stool softeners (if constipation is the cause) and warm baths. Your doctor may also prescribe a cream to soothe the inflamed area. Other options for fissures that do not heal with medication include treatment to relax the muscles around the anus (sphincters) or surgery.

In a colonoscopy, the physician passes the endoscope through your rectum and into the colon to examine the tissue of the colon wall for abnormalities such as polyps.

What is proctitis?

Proctitis refers to inflammation of the lining of the rectum. It can be caused by previous radiation therapy for various cancers, medications, infections or a limited form of inflammatory bowel disease (IBD). It may cause the sensation that you didn’t completely empty your bowels after a bowel movement, and may give you the frequent urge to have a bowel movement. Other symptoms include passing mucus through the rectum, rectal bleeding and pain in the area of the anus and rectum. Treatment for proctitis depends on the cause. Your doctor will discuss the appropriate course of action with you.

What are colon polyps?

Polyps are benign growths within the lining of the large bowel. Although most do not cause symptoms, some polyps located in the lower colon and rectum may cause minor bleeding. It is important to remove these polyps because some of them may later turn into colon cancer if left untreated.

What is colon cancer?

Colon cancer refers to cancer that starts in the large intestine. It can affect both men and women of all ethnic backgrounds and is the second most common cause of cancer deaths in the United States. Fortunately, it is generally a slow-growing cancer that can be cured if detected early. Most colon cancers develop from colon polyps over a period of several years. Therefore, removing colon polyps reduces the risk for colon cancer. Anal cancer is less common but curable when diagnosed early.

Most colon cancers develop from colon polyps over a period of several years. Therefore, removing colon polyps reduces the risk for colon cancer.

What are rectal ulcers?

Solitary rectal ulcer syndrome is an uncommon condition that can affect both men and women, and is associated with long-standing constipation and prolonged straining during bowel movement. In this condition, an area in the rectum (typically in the form of a single ulcer) leads to passing blood and mucus from the rectum. Treatment involves fiber supplements to relieve constipation. For those with significant symptoms, surgery may be required.

How is minor rectal bleeding evaluated?

Your doctor may examine the anus visually to look for anal fissures, cancer or external hemorrhoids, or the doctor may perform an internal examination with a gloved, lubricated finger to feel for abnormalities in the lower rectum and anal canal. If indicated, your doctor may also perform a procedure called colonoscopy. In this procedure, a flexible, lighted tube about the thickness of your finger is inserted into the anus to examine the entire colon. Sedative medications are typically given for colonoscopy to make you sleepy and decrease any discomfort. As an alternative, to evaluate your bleeding, your doctor may recommend a flexible sigmoidoscopy, which uses a shorter tube with a camera to examine the lower colon and rectum. To examine only the lower rectum and anal canal, an anoscope may be used. This very short (3 to 4 inch) tube is especially useful when your doctor suspects hemorrhoids, anal cancer or anal fissures.

What can I do to prevent further rectal bleeding?

This depends on the cause of the rectal bleeding. You should talk to your doctor about specific management options.

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Why Am I Pooping Blood, But There’s No Pain?

Why Am I Pooping Blood, But There’s No Pain?

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Medically reviewed by Saurabh Sethi, M. D., MPH — By Tim Jewell on February 7, 2023

Blood in your stool without pain is usually due to a hemorrhoid, but there could be other causes, like anal fissures, polyps, or more. If the health concern persists, a doctor can help you identify the cause and offer treatment options, like ointments for hemorrhoids or fissures.

It’s natural to feel like pooping blood should be an immediate cause for concern about a major health condition.

Not every cause requires urgent attention if you’re not feeling any pain when you poop. Pooping blood may simply be a short-term symptom linked to a treatable cause, like hemorrhoids.

But some causes of blood in your stool for long periods may need a diagnosis so that you can receive treatment before the condition becomes more severe.

Read on to learn more about the possible causes of pooping blood without pain, what other symptoms can prompt you to get medical attention, and how to manage rectal bleeding.

Hemorrhoids are among the most common causes of rectal bleeding without pain. But blood in your stool can also have other causes that you can manage at home or with over-the-counter medications.

Hemorrhoids

Hemorrhoids happen when veins in your rectum or anus swell and bulge out into the skin. They don’t always cause pain, but blood from the swollen veins can leak into the rectum and show up in your stool.

External hemorrhoids occur on the skin outside your anus and can cause bleeding there. But internal hemorrhoids develop inside your rectum. You can’t always tell when an internal hemorrhoid starts bleeding into your stool.

Some other symptoms that can help you figure out if an internal hemorrhoid is bleeding include:

• itchiness around your anus
• a burning sensation
• discomfort inside your bowels
• swelling around your anus

Most hemorrhoids go away without medical treatment.

Learn more about treatment options for bleeding hemorrhoids.

Anal fissures

Anal fissures happen when skin around your anus cracks and bleeds. They don’t always cause pain but may sting or burn, especially when fresh.

Symptoms of anal fissures include:

• visible torn skin on the anus
• anal swelling or skin growth
• blood when you wipe
• itchiness or burning around your anus

You don’t typically need any treatment for anal fissures unless you develop an infection in the open cuts.

Learn about foods that may help with anal fissures.

Polyps

Polyps are colon growths that look like mushrooms.

Polyps don’t usually cause pain. But they can leak blood into your intestines and cause blood in your stool.

Most polyps are just overgrowths of tissue and not a cause for concern. But some polyps can become cancerous without treatment.

Colorectal cancer

Polyps known as adenomas can develop into colorectal cancer, as cancer cells use blood vessels from your intestines to multiply. Blood from cancerous tumors can appear in your stool.

Colorectal cancer is often treatable if doctors detect it before it spreads to other organs. Doctors can remove cancerous polyps or cut out affected parts of your bowel to keep cancerous cells from spreading.

Inflammatory bowel disease

Inflammatory bowel disease (IBD) refers to conditions that cause inflammation in your digestive tract.

The most common types of IBD are ulcerative colitis in the large intestine and Crohn’s disease in any area of your digestive tract, including your stomach and small or large intestine.

IBD doesn’t consistently cause pain. But swelling can cause blockages of stool that injure tissue in your intestines and rectum as they pass through. This can cause blood from your intestines or rectum to come out with your stool.

Some forms of IBD are mild and manageable with diet or lifestyle changes. But some forms may result in pain, discomfort, or trouble pooping.

Color is a clue

The color of the blood in your stool may give you a clue as to the underlying health concern:

• Red: If the blood is bright red, the source is likely lower in your digestive tract. It’s likely something closer to the rectum or anus, like a hemorrhoid.
• Maroon: Dark red or maroon blood suggests that it is coming from higher up in the colon or even from the small intestine.
• Black: If the blood appears dark and tar-like, it may point to a health concern in the stomach, like a stomach ulcer.

Was this helpful?

Get medical attention if you experience severe pain in your abdomen after noticing blood in your poop, especially if the pain happens suddenly.

Other symptoms that can prompt you to contact a doctor include:

• dizziness
• constant feeling of pressure on your rectum
• chills
• fever
• nausea or vomiting without an obvious cause
• constipation
• diarrhea
• increased heart rate
• trouble peeing
• loss of consciousness

A doctor or gastroenterologist (a specialist sometimes called a GI doctor) may use several tests to diagnose the underlying health condition, including a:

• physical examination to look for other possible causes
• blood test to look for substances in the blood that indicate underlying causes
• stool sample for experts to analyze in a lab to find bacteria or other substances
• gastroscopy to look for stomach bleeding
• sigmoidoscopy to look at your rectum and lower colon
• colonoscopy to look for internal hemorrhoids or other causes

Here’s what you can do if you’re pooping blood but not experiencing any significant pain:

• Move around or get up at least once an hour to reduce pressure on your lower body from sitting.
• Use ointments or creams to treat hemorrhoids and fissures.
• Don’t strain when you poop, as this can cause hemorrhoids or fissures.
• Drink water to promote digestion and help keep your stool easier to pass.
• Eat more fiber to improve digestion.

You can also talk with a healthcare professional about surgery for severe hemorrhoids, cancer, or IBD.

Pooping blood without pain isn’t always an immediate cause for concern. Some causes go away on their own.

But be sure to get medical help if you have blood in your stool for a long period. Talk with a healthcare professional if you start to notice pain and other disruptive symptoms, such as diarrhea or fever. They can diagnose the cause and help you get treatment.

Last medically reviewed on February 7, 2023

How we reviewed this article:

Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references. You can learn more about how we ensure our content is accurate and current by reading our editorial policy.

• Colorectal cancer. (n.d.).
  cancer.org/cancer/colon-rectal-cancer.html
• Fontem RF, et al. (2022). Internal hemorrhoid.
  ncbi.nlm.nih.gov/books/NBK537182/
• Sabry AO, et al. (2022). Rectal bleeding.
  ncbi.nlm.nih.gov/books/NBK563143/

Our experts continually monitor the health and wellness space, and we update our articles when new information becomes available.

Current Version

Feb 7, 2023

Written By

Tim Jewell

Edited By

A. L. Heywood

Medically Reviewed By

Saurabh Sethi, MD, MPH

Copy Edited By

Sofia Santamarina

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Medically reviewed by Saurabh Sethi, M.D., MPH — By Tim Jewell on February 7, 2023

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Treatment of hemorrhoids without surgery and other effective methods

Facts about treatment:

• Most often, a person who has symptoms does not seek specialized medical help for a long time and tries to treat himself.
• Pregnant women often have symptoms, but they usually go away at the end of the pregnancy. However, some women may develop chronic hemorrhoids. With exacerbation of chronic hemorrhoids, specialized medical care is needed.
• For any bleeding from the anus, it is very important to consult a specialist, as it can be caused not only by hemorrhoids, but also by other more serious diseases.
• About half of the patients who come to a specialized medical facility to treat hemorrhoids have other anorectal diseases, such as anal fissure, anal fissures or irritation of the perianal skin.
• Outpatient treatments are usually relatively painless.
• Surgical treatment is required only for a small number of patients, drug therapy and modern minimally invasive techniques are sufficient.

What are hemorrhoids?

Commonly described as “anal and rectal varicose veins”. In fact, these are enlarged, distended blood vessels located in the anal canal and lower rectum. Depending on the location, there are 2 types: external and internal.

External formed near the anus and covered with very sensitive skin. If a blood clot forms in one of the external hemorrhoids, swelling develops, which causes severe pain. Feels like a hard, painful hemorrhoid. Bleeding from it occurs only if the skin on its surface is damaged.

Internal hemorrhoids develop inside the anal canal where it passes into the rectum. Usually internal knots are painless. They are covered with a mucous membrane, the same that lines the inner surface of the rectum. The most common symptoms are painless bleeding and prolapse (prolapse) of hemorrhoids during bowel movements.

Sometimes hemorrhoids fall out of the anal canal, but can return to their place on their own. Sometimes manual adjustment is required. Very rarely, internal hemorrhoids can cause severe pain. This occurs with the complete loss of nodes and the development of blood clots in them.

What is the cause of the disease?

An increase in pressure in the veins of the rectum and anal canal leads to their stretching.

Factors that may cause this include:

• Age over 35;
• Chronic constipation or diarrhea;
• Pregnancy;
• Heredity;
• Overuse of medicinal laxatives or enemas;
• Severe straining during bowel movements;
• Spending a lot of time in the toilet (reading, etc.).

Due to these reasons, the elastic structures that support the veins in the anal canal are stretched. As a result of this, the lumen of the veins continues to expand, their walls become thinner, and bleeding occurs. A complex of dilated vessels with a mucous membrane covering them is called internal hemorrhoids. If the stretching of the veins and increased pressure in them persist, the hemorrhoids may increase, stretch and fall out of the canal.

External hemorrhoids can also enlarge and cause discomfort. The most common complication is thrombosis. As a result, an elastic “bump” is formed at the edge of the anal passage. Its formation is based on excessive accumulation of blood due to the fact that the lumen of the vessel is blocked by a thrombus. This can happen as a result of prolonged straining or sitting (with constipation, during travel, childbirth).

Symptoms

If you notice any of the following symptoms, make an appointment with a proctologist for a consultation:

• Bleeding that occurs during bowel movements.
• Prolapse of hemorrhoids during bowel movements.
• Itching of the perianal region.
• Pain in the anus.
• Painful “bumps” in the anus.

Do hemorrhoids lead to cancer?

No. There is no connection between the development of this disease and malignant tumors. However, some symptoms, especially bleeding, are also characteristic of rectal and colon cancer and other diseases of the digestive system. Therefore, it is very important to consult a coloproctologist if any symptoms of hemorrhoids appear. Today, there are a wide range of medicines freely sold in pharmacies that can reduce the manifestations of hemorrhoids, but should not be treated on their own.

At your appointment with a coloproctologist, after a qualified examination and assessment of symptoms, a treatment will be prescribed that is appropriate for your situation.

Treatment

Treatment of hemorrhoids in men

9 0004 In men, the causes of the development of the disease are most often associated with hard physical labor, a sedentary lifestyle and malnutrition. At the proctology clinic, we use modern diagnostic methods to determine the extent of the disease and choose the most appropriate treatment plan for your case.

One of the most effective non-surgical treatments for hemorrhoids in men is sclerotherapy. This minimally invasive method involves the injection of a special substance that causes the hemorrhoids to narrow and then disappear.

However, in some cases, when hemorrhoids are advanced or do not respond to conservative treatment, surgical removal may be required. Our highly trained surgeons perform operations using modern analgesics and techniques, minimizing pain and reducing recovery time.

Treatment of hemorrhoids in women

Hemorrhoids in women are a common disease, especially during pregnancy and after childbirth. Features of the treatment of hemorrhoids in women are associated with the uniqueness of the female body, in particular, with the changes that occur in the body during childbearing and in the postnatal period.

KKMC offers individualized treatment programs for women. First, we conduct a thorough diagnosis in order to determine the stage of the disease and select the most effective treatment plan.

One non-surgical treatment approach is laser therapy. This is a painless and minimally invasive method that allows you to effectively deal with hemorrhoids, minimizing risks and reducing recovery time.

In cases where the disease reaches a more serious stage or does not respond to conservative treatment, surgical removal may be required. Our specialists have extensive experience in performing such operations, ensuring maximum safety and comfort for patients.

After treatment, we help our patients to prevent recurrence. This includes advice on nutrition, physical activity, and overall lifestyle.

Special attention in our clinic is given to the treatment of hemorrhoids in pregnant and lactating women. We use methods that are safe for both mother and child and reduce the risk of developing hemorrhoids during this important period in a woman’s life.

General recommendations

Increasing dietary fiber and fluid intake may help reduce symptoms. Good sources of dietary fiber are bread and bran products, fruits and vegetables. Reducing the force and duration of straining during a bowel movement will reduce the pressure on the hemorrhoids and prevent their prolapse. Warm sitz baths for 10-15 minutes can also help relieve the condition.

External hemorrhoids

Acute pain in the development of thrombosed external hemorrhoids persists for 2-4 days. Then the pain gradually subsides and the resulting “bump” will eventually decrease and go away. A small anal fringe (fold of skin) may remain at the site of the thrombosed node. The choice of treatment depends on the symptoms. If the pain is tolerable and its intensity decreases, conservative therapy and non-surgical treatment of hemorrhoids are prescribed: effective painkillers and the above general measures. With unbearable pain or worsening of the condition, a small skin incision is made above the hemorrhoid and removed. This procedure is performed on an outpatient basis under local anesthesia.

Internal hemorrhoids

Treatment depends on the symptoms and the degree of prolapse. For most patients, compliance with the above diet and lifestyle is sufficient. Enlarged plexuses with bleeding and prolapse can often be treated on an outpatient basis in one of several ways.

• Ligation of hemorrhoids with latex rings. This method is used to treat internal hemorrhoids, when the nodes fall out only during bowel movements. A small latex ring is placed on the hemorrhoidal node, which pulls its base with the vessels passing through it, stopping the blood flow in the node. After a few days, the knot along with the ring disappears, and the resulting wound heals within 1-2 weeks. This procedure is most often virtually painless.
• Sclerotherapy and infrared photocoagulation. These treatments are used for frequent bleeding, in which the nodes do not fall out of the anal canal.
• Hemorrhoidectomy is a surgical operation to remove nodes. This is the best way to achieve the complete disappearance of all symptoms. Surgical removal of internal plexuses is used for prolapsed and non-retractable nodes, or when there is no effect from outpatient treatment, or when outpatient treatment is not possible for various reasons. During a hemorrhoidectomy, excess tissue that causes bleeding and prolapse is removed. The operation can be performed using sedative and local anesthesia, regional or general anesthesia. Also, this operation can be performed on an outpatient basis, however, under certain circumstances, hospitalization may be required. After the operation, it is imperative to observe a period of restriction of activity for recovery. The likelihood of recurrence after hemorrhoidectomy is quite small. Hemorrhoidectomy can also be performed using a laser. Using a laser makes the procedure somewhat more expensive.
• Other treatments include cryotherapy, bipolar coagulation. Cryotherapy was a popular treatment modality 20 years ago. During this procedure, hemorrhoids are frozen, which is often accompanied by significant pain. With bipolar electrocoagulation, the tissue of the hemorrhoid is destroyed under the influence of an electric current. None of these methods has been widely adopted due to their shortcomings.

Preparation for surgery

Special preparation for surgery is not required, it is enough to perform a cleansing enema the day before and in the morning on the day of surgery and refuse to eat and drink on the day of surgery. Surgical treatment for patients turns into a twenty-minute sleep with complete relief from the problem.

THEM. Sechenov

Postoperative period

tissue capacity can reach 1.5 -2 month. The duration of the period of disability rarely exceeds 7-10 days, and the use of modern tissue separation technologies allows the operated patient to be transferred to an outpatient follow-up regimen already on the second day after the surgical procedure.

Prevention

Preventive measures include: correct diet, active healthy lifestyle, good hygiene. Laxatives should only be taken if absolutely necessary. To prevent constipation, drink enough fluids, the diet should be rich in organic fiber (vegetables and fruits).

Pain during bowel movements: causes

In 2010, the second, revised and supplemented edition of the illustrated guide “Hemorrhoids” was published under the guidance of the country’s chief coloproctologist, Academician of the Russian Academy of Medical Sciences G.I. Vorobyov, Professor Yu.A. Shelygin and Associate Professor L.A. Blagodarny. The authors assumed that critical comments could be made on the content of this book and promised to accept all comments and suggestions with gratitude. The team of authors of the Guide to Proctology, professors V.L. Rivkin, S.N. Fine, A.S. Bronshtein and Ph.D. VKAn, who in the section “anal fissure” offered to answer the question: why in some cases the anal fissure heals quickly and steadfastly, while in others it quickly passes into the chronic stage? We decided to take advantage of the offers to speak out and make our opinion available to everyone.

The postulate that the main predisposing factor in the development of hemorrhoids is hypodynamia with constant stagnation of blood circulation in the pelvic organs, and primarily in the rectum, raises doubts. In the literature available to us on discussing the results of experimental prolonged hypokinesia and hypodynamia, we were unable to find a single reference to the development of hemorrhoids in the subjects. The authors only mention the slowdown in their passage of food through the intestines. Stagnation during hypodynamia and straining occurs mainly in the veins of the external hemorrhoidal plexus, which gives blood to the iliac veins, and not in any way internal. From the internal hemorrhoidal plexus, blood flows into the portal vein system (an increase in pressure in which occurs exclusively in liver diseases) along the branches of the superior rectal vein, located next to the arterial vessels of the same name. The blood through the veins of the lower extremities and the iliacs moves due to the contraction of the skeletal muscles, therefore, during hypodynamia, it stagnates, and when straining, the iliac veins are compressed by the internal organs and an even greater blood stasis occurs in them. Of course, one should not forget about a large number of porto-caval anastomoses, including those between the upper, middle and lower hemorrhoidal plexuses, but we believe that the increase in blood supply to the internal hemorrhoids caused by them is only a secondary predisposing factor that is not of paramount importance.

We, with a fair degree of confidence, assume that the basis for the development of hemorrhoids is inadequate defecation. By this term, we mean any deviation from the standard of human defecation: daily, single, mushy stools without much straining. With the slow passage of soft feces, there is a smooth compression of the internal hemorrhoids, and the blood is evacuated from them through the corresponding veins. With the passage of dense fecal masses or a high rate of emptying, the nodes do not have time to empty – then the filled nodes become an obstacle to passing feces. There is either damage to the node with external or internal bleeding (the first is a symptom of the disease, the second is internal thrombosis), or the node is shifted from the place of fixation, with damage to the ligamentous retaining complex (which creates the possibility for the appearance of the second symptom of the disease – prolapse). Thus, the causes of the onset and progression of hemorrhoids are: defecation with dense feces with straining, the so-called “rapid” defecation even with liquid feces (since the hemorrhoids do not have time to get rid of the blood filling them and are injured by passing feces), multiple defecation with diarrhea (which also causes corrosion, self-digestion of the mucosa over the nodes).

Neither we nor our colleagues observed an isolated chronic anal fissure as an independent disease. That is, without the “associated” hemorrhoids. This suggests that there is only an acute anal fissure that heals on its own. A chronic anal fissure is a complication of chronic prolapsed hemorrhoids. It occurs only in places of sliding and prolapse of hemorrhoids, which tear the mucosa during sliding and prolapse (more often from behind, less often from front) in places of its best fixation. And it does not require the treatment of chronic anal fissure sphincterotomy, because hypertonicity and spasm of the sphincter are the result of a rupture of the mucous membrane of the anal canal (with penetration into the submucosal layer, to the nerve endings, feces) and not the cause of a mucosal defect. After all, they refused from longitudinal myotomy in diverticular disease! And what would neurologists say about the proposal to perform myotomy in myotonic radicular syndrome? Mandatory in the treatment of chronic anal fissure is suture ligation of nodes with fixation of the mucosa after excision of the fissure by any method and 4-finger divulsion.

We are absolutely sure that a relapse-free postoperative course after any operation on the anus is possible only if the patient observes the rules of nutrition and normalization of defecation. Those who cannot normalize impaired bowel movements should be operated on only according to absolute indications, especially persistently warning patients about the possible imminent emergence of new problems: prolapse of the mucous membrane or the entire rectum, the occurrence of painful ruptures of the mucous membrane of the anal canal and perianal skin.

A great many classifications of hemorrhoids have been created and continue to be created in the context of the authors’ point of view. But all of them reflect the established tradition of considering hemorrhoids not as a disease, but as an annoying nuisance (after all, almost none of the scientists we respect use the term Hemorrhoidal Disease – everyone prefers the word Hemorrhoids). We would like to correct the current and, in our opinion, the wrong state of affairs. Therefore, the proposed classification immediately answers the question of further treatment tactics (like all classifications of surgical diseases).

Allow me to introduce you to the classification of hemorrhoidal disease, which term should long ago replace the outdated concept of “hemorrhoids”.

Hemorrhoidal disease, as a disease, has acute and chronic variants of the course.

Acute hemorrhoids can develop only according to 2 scenarios: according to the type of thrombosis and bleeding.

OH according to the thrombotic type can be external (primary or repeated, uncomplicated and complicated by inflammation) and internal, uncomplicated and complicated (prolapse, strangulation, inflammation and necrosis). External uncomplicated hemorrhoidal thrombosis can be both operated on (thrombectomy) and treated conservatively, and complicated operation is mandatory. Internal uncomplicated is best treated conservatively, and the issue of surgery is decided after the completion of the course of treatment. Complicated internal hemorrhoidal thrombosis, we prefer to operate urgently, in a minimal amount, without suturing the mucosa.

Bleeding OH should be divided according to the intensity of bleeding: with the development of posthemorrhagic anemia or not. If blood transfusion is indicated, then these are indications for radical surgery or suture ligation.

Chronic hemorrhoids are diagnosed in the stage of exacerbation or remission, and can also be internal and combined (i.e. internal hemorrhoids with a pronounced external component). The concept of chronic external hemorrhoids should not be fundamentally (since there is no cavernous tissue in the external nodes, but there is only dysplasia of the extensive venous network). When establishing a diagnosis of chronic external hemorrhoids, we mean either repeated acute hemorrhoidal thrombosis, or the consequences of this thrombosis, or prolapse of the anal canal mucosa, or hypertrophy of the anal velvet stripes (according to some authors – fringes) – which refer to hemorrhoidal disease only “territorially”.

Next, we should highlight the forms of chronic hemorrhoids. From our point of view, there are only 5 of them.

1. Uncomplicated bleeding chronic hemorrhoids have, as we believe, 3 stages:

1.1. Occasionally bleeding and requiring only general recommendations on hygiene and nutrition.

1.2. Bleeding with constipation, which requires a change in the nutrition system, it is possible to use latex ligation, infrared coagulation, and other similar methods.

1.3. Bleeding with every bowel movement and physical activity. For the treatment of this stage of the disease, it is possible to use one of the modern methods proposed by science and practice. We prefer a radical operation for node hypertrophy of 3-4 degrees, suture ligation for 2-3 degrees, it is possible to perform the Longo operation with an anastomosis level in the upper third of the anal canal.

2. Uncomplicated chronic prolapsed hemorrhoids should be divided into 4 stages:

2.1. The nodes slide out during defecation with dense feces, palpation increasing the external component, and usually all the patient’s problems end after the normalization of the feces consistency. With hypertrophy of nodes 2-3 tbsp. possible latex ligation.

2.2. Nodules fall out in the form of “balls” of various sizes and are independently reduced into the anal canal – suture ligation can be an ideal treatment if there have been no thromboses before, and there are no dense inclusions in the form of organized blood clots in the nodes. An alternative way is possible: latex ligation followed by submucosal sclerotherapy to fix the mucosa with aseptic inflammation. But we consider this way less reliable. If seals are present, knots should be removed.

2.3. Knots fall out during defecation and physical activity and require manual reduction. Most often this happens due to dense inclusions in the nodes after thrombosis – a radical operation has no alternative.

2.4. They do not reduce, constantly being outside – it is possible to cut them off with suturing wounds circularly or in sectors, but with mandatory suture fixation of the mucosa in the upper part of the anal canal.

3. Combined chronic hemorrhoids – with a combination of bleeding and prolapse of nodes. Staging in this case should reflect both forms of chronic hemorrhoids (for example: 2-3 with stage 3 prolapsed hemorrhoids and bleeding with constipation).

4. Symptomatic or compensatory chronic hemorrhoids (with weakness of the anal sphincter, hypertrophy of the hemorrhoids allows you to retain gases and intestinal contents, but outwardly causes the wrong impression of the need for treatment). Usually such patients are referred to the proctologist by gynecologists and endoscopists. Treatment in this case should begin with attempts to restore the work of the sphincter apparatus, but in no case should hypertrophied nodes be reduced with various benefits, because. this can lead to incontinence.

5. Complicated chronic hemorrhoids. Complications of chronic hemorrhoids in our opinion should be considered:

Formation of a distal anal stricture

Formation of chronic anal fissure

Chronic anemization requiring blood transfusion

Prolapse of the anal canal mucosa more than 1/3 of the circumference

Purulent-inflammatory processes.

We consider all of these listed complications to be an indication for surgical intervention in a planned order, except for the last one: the opening of abscesses is necessary immediately after diagnosis.

The main substrate of hemorrhoidal disease are hemorrhoids, so it is necessary to be very clear about how enlarged they are. This allows you to more clearly and clearly navigate the planning of methods and methods of treatment. For example, if the hypertrophy of the node is maximum and there are no signs of weakness of the anal sphincter, then it is tactically wrong to perform any intervention without reducing the size of the nodes. And vice versa, planning a radical operation with slightly enlarged nodes is super-radical. It is necessary to focus on the size of the nodes and with bleeding hemorrhoids: even with 1-2 stages of the disease, but 3-4 degrees of hypertrophy of the nodes, it is necessary to reduce them using various methods. Therefore, we propose to introduce a graduation of the degrees of hypertrophy of hemorrhoids. We see it as the next one.

The lower pole of the node does not reach the dentate line – they do not need to be reduced.
The lower pole of the node reaches the dentate line and prolapses below – latex ligation, infrared coagulation, etc. can be performed.
The node does not continue below the Hilton line or prolapse into the lower ampulla – we are in favor of suture ligation with a possible reduction in the size of the node.
The node descends below the Hilton line and prolapses in the lower ampullar region. The removal of the node according to one of the surgical methods is, obviously, the “gold standard”.

The problem of hemorrhoidal disease is anatomically and physiologically related to the functioning of the muscular obturator apparatus of the rectum, and the most important in this regard are the tone of the external and internal sphincters, the contractility of the sphincter and levators. To measure these indicators, instrumental sphincterometry and balloonography (rectal manometry), defecation proctography are used. However, the use of special equipment is the prerogative of research centers rather than a practicing proctologist. Therefore, we insist on introducing one more section into the classification:

Degrees of weakness of the anal sphincter.

The finger inserted into the anus is covered by the anal canal throughout, provides elastic resistance to transverse movements, volitional efforts (retracting the anus and squeezing the inserted finger) are active, strength and amplitude are pronounced.
The anal canal does not tightly cover the inserted finger, volitional efforts are normal.
The finger inserted into the anal canal moves freely in the transverse direction, volitional efforts are normal or reduced.
Perhaps the free painless introduction of 2 fingers into the anal canal, volitional efforts are weakened.
The anal canal is gaping, volitional efforts are barely defined or absent.

Information about the condition of the anal sphincter is necessary when planning interventions in the anus. If, with a degree of weakness of 0-1, divulsion can be produced in full, then at degree 2, it should be limited to only 2 fingers. At the 3rd degree, all interventions are contraindicated until the end of the complex of measures to tone the muscles and reduce the degree of weakness to the 2nd; interventions should only be minimally invasive, without divulsion. In Grade 4 weakness, any surgical aid should be considered extremely dangerous in terms of incontinence.