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Hemorrhoids

Definition, Description, Causes and symptoms, Diagnosis, Treatment, Alternative treatment, Prognosis, Prevention

Hemorrhoids are enlarged veins in the anus or lower rectum. They often go unnoticed and usually clear up after a few days, but can cause long-lasting discomfort, bleeding and be excruciatingly painful. Effective medical treatments are available, however.

Description

Hemorrhoids (also called piles) can be divided into two kinds, internal and external. Internal hemorrhoids lie inside the anus or lower rectum, beneath the anal or rectal lining. External hemorrhoids lie outside the anal opening. Both kinds can be present at the same time.

Hemorrhoids are a very common medical complaint. More than 75% of Americans have hemorrhoids at some point in their lives, typically after age 30. Pregnant women often develop hemorrhoids, but the condition usually clears up after childbirth. Men are more likely than women to suffer from hemorrhoids that require professional medical treatment.

Causes and symptoms

Precisely why hemorrhoids develop is unknown. Researchers have identified a number of reasons to explain hemorrhoidal swelling, including the simple fact that people's upright posture places a lot of pressure on the anal and rectal veins. Aging, obesity, pregnancy, chronic constipation or diarrhea, excessive use of enemas or laxatives, straining during bowel movements, and spending too much time on the toilet are considered contributing factors. Heredity may also play a part in some cases. There is no reason to believe that hemorrhoids are caused by jobs requiring, for instance, heavy lifting or long hours of sitting, although activities of that kind may make existing hemorrhoids worse.

The commonest symptom of internal hemorrhoids is bright red blood in the toilet bowl or on one's feces or toilet paper. When hemorrhoids remain inside the anus they are almost never painful, but they can prolapse (protrude outside the anus) and become irritated and sore. Sometimes, prolapsed hemorrhoids move back into the anal canal on their own or can be pushed back in, but at

Clinical photo of a thrombosed external hemorrhoid. (Custom Medical Stock Photo. Reproduced by permission.) Clinical photo of a thrombosed external hemorrhoid. (Custom Medical Stock Photo. Reproduced by permission.)

other times they remain permanently outside the anus until treated by a doctor.

Small external hemorrhoids usually do not produce symptoms. Larger ones, however, can be painful and interfere with cleaning the anal area after a bowel movement. When, as sometimes happens, a blood clot forms in an external hemorrhoid (creating what is called a thrombosed hemorrhoid), the skin around the anus becomes inflamed and a very painful lump develops. On rare occasions the clot will begin to bleed after a few days and leave blood on the underwear. A thrombosed hemorrhoid will not cause an embolism.

Diagnosis

Diagnosis begins with a visual examination of the anus, followed by an internal examination during which the doctor carefully inserts a gloved and lubricated finger into the anus. The doctor may also use an anoscope, a small tube that allows him or her to see into the anal canal. Under some circumstances the doctor may wish to check for other problems by using a sigmoidoscope or colonoscope, a flexible instrument that allows inspection of the lower colon (in the case of the sigmoidoscope) or the entire colon (in the case of the colonoscope).

Treatment

Hemorrhoids can often be effectively dealt with by dietary and lifestyle changes. Softening the feces and avoiding constipation by adding fiber to one's diet is important, because hard feces lead to straining during defecation. Fruit, leafy vegetables, and whole-grain breads and cereals are good sources of fiber, as are bulk laxatives and fiber supplements such as Metamucil or Citrucel. Exercising, losing excess weight, and drinking six to eight glasses a day of water or another liquid (not alcohol) also helps.

Rubber band ligation is probably the most widely used treatment for internal hemorrhoids. An applicator is used to place one or two small rubber bands around the base of the hemorrhoid, cutting off its blood supply (figures A and B). After 3-10 days, the rubber bands and the hemorrhoid fall off, leaving a scab which disappears within a week or two. (Illustration by Electronic Illustrators Group.) Rubber band ligation is probably the most widely used treatment for internal hemorrhoids. An applicator is used to place one or two small rubber bands around the base of the hemorrhoid, cutting off its blood supply (figures A and B). After 3-10 days, the rubber bands and the hemorrhoid fall off, leaving a scab which disappears within a week or two. (Illustration by Electronic Illustrators Group.)

Soap or toilet paper that is perfumed may irritate the anal area and should be avoided, as should excessive cleaning, rubbing, or wiping of that area. Reading in the bathroom is also considered a bad idea, because it adds to the time one spends on the toilet and may increase the strain placed on the anal and rectal veins. After each bowel movement, wiping with a moistened tissue or pad sold for that purpose helps lessen irritation. Hemorrhoid pain is often eased by sitting in a tub of warm water for about 10 or 15 minutes two to four times a day (sitz bath). A cool compress or ice pack to reduce swelling is also recommended (the ice pack should be wrapped in a cloth or towel to prevent direct contact with the skin). Many people find that over-the-counter hemorrhoid creams and foams bring relief, but these medications do not make hemorrhoids disappear.

When painful hemorrhoids do not respond to home-based remedies, professional medical treatment is necessary. The choice of treatment depends on the type of hemorrhoid, what medical equipment is available, and other considerations.

Rubber band ligation is probably the most widely used of the many treatments for internal hemorrhoids (and the least costly for the patient). This procedure is performed in the office of a family doctor or specialist, or in a hospital on an outpatient basis. An applicator is used to place one or two small rubber bands around the base of the hemorrhoid, cutting off its blood supply. After three to 10 days the bands, the hemorrhoid falls off, leaving a sore that heals in a week or two. Because internal hemorrhoids are located in a part of the anus that does not sense pain, anesthetic is unnecessary and the procedure is painless in most cases. Although there can be minor discomfort and bleeding for a few days after the bands are applied, complications are rare and most people are soon able to return to work and other activities. If more than one hemorrhoid exists or if banding is not entirely effective the first time (as occasionally happens), the procedure may need to be repeated a few weeks later. After five years, 15–20% of patients experience a recurrence of internal hemorrhoids, but in most cases all that is needed is another banding.

External hemorrhoids, and some prolapsed internal hemorrhoids, are removed by conventional surgery in a hospital. Depending on the circumstances, this requires a local, regional, or general anesthetic. Surgery does cause a fair amount of discomfort, but an overnight hospital stay is usually not necessary. Full healing takes two to four weeks, but most people are able to resume normal activities at the end of a week. Hemorrhoids rarely return after surgery.

Alternative treatment

Like mainstream practitioners, alternative practitioners stress the importance of a high-fiber diet. To prevent hemorrhoids by strengthening the veins of the anus, rectum, and colon, they recommend blackberries, blueberries, cherries, vitamin C, butcher's broom (Ruscus aculeatus), and flavonoids (plant pigments found in fruit and fruit products, tea, and soy). Herbal teas, ointments, and suppositories, and other kinds of herbal preparations, are suggested for reducing discomfort and eliminating hemorrhoids. In particular, pilewort (Ranunculusficaria), applied in an ointment or taken as a tea, can reduce the pain of external hemorrhoids. Acupuncture, acupressure, aromatherapy, and homeopathy are also used to treat hemorrhoids.

Prognosis

Hemorrhoids do not cause cancer and are rarely dangerous or life threatening. Most clear up after a few days without professional medical treatment. However, because colorectal cancer and other digestive system diseases can cause anal bleeding and other hemorrhoid-like symptoms, people should always consult a doctor when those symptoms occur.

Prevention

A high-fiber diet and the other lifestyle changes recommended for coping with existing hemorrhoids also help to prevent hemorrhoids. Not straining during bowel movements is essential.

Resources

BOOKS

Billingham, Richard P. "Hemorrhoids, Anal Fissure, and Anorectal Abscess and Fistula." In Conn's Current Therapy, 1996, ed. Robert E. Rakel. Philadelphia: W. B. Saunders Co., 1996.

Burton Goldberg Group. Alternative Medicine: The Definitive Guide. Puyallup, WA: Future Medicine Publishing, Inc.,1993.

PERIODICALS

Pfenninger, John L. "Modern Treatments for Internal Haemorrhoids." British Medical Journal 314 (1997): 1211+.

Surrell, James. "Nonsurgical Treatment Options for Internal Hemorrhoids." American Family Physician (Sept. 1995): 821+.

ORGANIZATIONS

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. (800) 891-5389. <http://www.niddk.nih.gov/health/digest/nddic.htm>.

Howard Baker

KEY TERMS


Anus—The opening at the lower end of the rectum. The anus and rectum are both part of the large intestine, a digestive system organ.

Colon—The major part of the large intestine, a digestive system organ.

Defecation—Passage of feces through the anus.

Embolism—Obstruction of blood flow in an artery by a blood clot or other substance arising from another site. An untreated embolism can endanger health and even cause death.

Enema—The introduction of water or another liquid into the bowels through a tube inserted into the anus. Enemas are used to treat constipation and for other purposes.

Feces—Undigested food and other waste that is eliminated through the anus. Also called stools.

Rectum—The lower section of the large intestine, a digestive system organ. After food has passed through the stomach and intestines and been digested, the leftover material, in the form of feces, enters the rectum, where it stays until defecation.

Suppository—A medicinal substance that slowly dissolves after being inserted into the rectum (or other body cavity).

Additional topics

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