Hemorrhoids

Hemorrhoid is a common condition in which swelling occurs in the veins around the anus, similar to varicose veins in legs. It is also known as piles. The veins around the anus tend to stretch when the pressure is raised inside them, causing them to become swollen. This can happen due to several reasons.

It is not well understood as to what precisely causes hemorrhoids. Generally, it is associated with conditions that increase pressure in the veins around the anus. The following are the most common causes.

• Straining to have a bowel movement secondary to constipation
• Chronic diarrhea
• Pregnancy
• Obesity
• Liver disease
• Low fiber diet
• Anal intercourse

There are two sets of veins that can get swollen, causing hemorrhoids.

• Internal hemorrhoids: When the veins inside the rectum are affected.
• External hemorrhoids: When the veins under the skin around the anus are affected.

Although hemorrhoids are a common condition, the exact prevalence is unknown as most patients are asymptomatic and do not seek medical attention. Commonly, this condition occurs in persons 45 to 65 years of age.
Advancing age enhances the risk of hemorrhoids as it leads to weak tissues that support the veins in the rectum and anus. Similar mechanisms increase the risk of hemorrhoids in pregnant women, as increased pressure on the anal region from the baby's head causes swollen veins.

Signs and symptoms depend upon the type of hemorrhoids.

Internal hemorrhoids: These rarely cause symptoms as they lie inside the rectum. Painless bleeding evident on toilet paper or toilet bowl is the most common sign. Other symptoms include soiling, pain, and irritation and generally occur when prolonged stretching causes these hemorrhoids to fall out (prolapse) through the anus to the outside of the body (protruding hemorrhoids).

External hemorrhoids: Since they lie under the skin, they can lead to itching, discomfort, or bleeding. Sometimes external hemorrhoids can present as a hard and tender lump if a blood clot is formed in the veins causing extreme pain and swelling.

Several conditions can cause signs and symptoms similar to hemorrhoids. These include:

• Fissure
• Fistula
• Abscess
• Polyps
• Proctitis
• Skin tags
• Inflammatory bowel disease
• Cancer

First-line treatment is generally conservative and includes the following measures:

• A high-fiber diet increases daily hydration, and stool softeners can help decrease bleeding due to hemorrhoids by as much as 50%.
• A warm-water sitz bath for 10-15 minutes may help reduce the pain temporarily.
• Pain medications like acetaminophen or ibuprofen may help reduce pain and inflammation.

a. Over the counter (OTC): Many topical over-the-counter remedies may provide temporary relief.
1. Cream or suppository containing hydrocortisone.
2. Skin-protecting agents containing zinc oxide
3. Decongestants containing phenylephrine
4. Topical anesthetics containing lidocaine.

b. Prescription:
1. Topical nitroglycerin 0.4% ointment that is commonly used for anal fissures may also help reduce pain due to thrombosed hemorrhoids
2. Topical nifedipine may also help with pain relief, but it has to be compounded by a pharmacy.
3. Botulinum toxin as a single injection reduces the pain of thrombosed external hemorrhoids.

If hemorrhoids don't resolve with medical therapy, office-based and surgical procedures are used to treat them effectively.

a. Clinic-based procedure:
1. Rubber band ligation: In this procedure, the base of the internal hemorrhoid is tied with one or two rubber bands to cut off the blood flow. After the procedure, the hemorrhoid usually falls off within a week.
2. Sclerotherapy: in this procedure, a chemical solution is directly inserted into hemorrhoids, shrinking them.
3. Infrared photocoagulation: in this procedure, the heat created by infrared light causes scar tissue which cuts off the blood supply to hemorrhoids.

b. Surgical procedures:
1. Hemorrhoidectomy is a surgical procedure to remove hemorrhoids refractory to other therapies, which is usually done under general or spinal anesthesia. There are several techniques that a surgeon might choose from to perform excision of hemorrhoidal tissue. Complications include pain and urinary retention secondary to spinal anesthesia.
2. Stapled hemorrhoidopexy: This procedure involves using a stapling device to remove hemorrhoidal tissue and is only applicable for internal hemorrhoids. Complications include an increased risk of recurrence and prolapse compared to hemorrhoidectomy in addition to pain and bleeding.

Prognosis is generally good, and symptoms usually resolve with conservative remedies and over-the-counter medications. However, a small portion of patients needs surgical management for refractory or recurring hemorrhoids. Very rarely do hemorrhoids cause chronic bleeding leading to anemia.

• As hemorrhoids are more prevalent in those who suffer from constipation, it is vital to have regular and soft bowel movements to avoid straining.
  The following are some of the ways to help prevent hemorrhoids.
• Incorporate a fiber-rich diet.
• Drink plenty of water.
• Perform regular exercise.
• Do not avoid the urge to defecate.
• Avoid sitting on the toilet for long periods, especially on your phone.

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