Ohio GI [Hemorrhoids]

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DEFINITION Hemorrhoids develop from dilated veins in the lower rectum. Hemorrhoids may be internal (located inside the lower rectum) or external (under the skin around the anus) ( show figure 1 ). Both types of hemorrhoids can be present at the same time.

Internal hemorrhoids are classified further based upon the degree to which they protrude from the anal canal. This grading system is important since the grade in part determines which type of treatment is best. According to this grading system:

Grade I hemorrhoids may bulge into the anal canal but do not protrude through the anus.

Grade II hemorrhoids protrude through the anus during straining and defecation, but return spontaneously.

Grade III hemorrhoids protrude through the anus with defecation or straining but do not return spontaneously, requiring the patient to gently push it back into its normal position with a finger.

Grade IV hemorrhoids cannot be manually returned to their normal position.

No widely used grading system exists for external hemorrhoids.

SYMPTOMS Symptoms of hemorrhoids can include the following:

Painless bleeding
Itching in the anal region
Protrusion of an internal hemorrhoid through the anus
Pain
Leakage of feces

Bleeding Painless bleeding with bowel movement is a common symptom of hemorrhoids. At the end of defecation, bright red blood may coat the stool, drip into the toilet, or appear on toilet tissue after wiping. The amount of blood is usually small. However, blood may discolor the toilet bowl, giving it the appearance of heavy bleeding.

Less commonly, bleeding can be heavy. In rare cases, chronic blood loss from bleeding can cause anemia, resulting in fatigue, weakness, or other associated symptoms.

Without examination, it is not possible to know if hemorrhoids or other, possibly more serious, causes are the source of rectal bleeding. Thus, anyone with bleeding from the rectum should be examined.

Itching Hemorrhoids commonly cause itching and irritation of skin around the anus. Itching may be caused by a combination of factors, including the following:

Internal hemorrhoids may allow leakage of feces, which can be irritating to the skin around the anus.

Overzealous cleansing may irritate the region around the anus

Patients with external hemorrhoids may develop small growths of skin, known as skin tags. These can be difficult to keep clean, resulting in prolonged contact of fecal material with skin around the anus, causing localized irritation.

Swelling of hemorrhoids may cause itching and irritation.

Pain Pain may develop in patients who have of blood clots (thrombosis) within the hemorrhoid. This can occur within both external and internal hemorrhoids. Thrombosed external hemorrhoids are bluish-purple masses that extend from the anal to the perianal skin ( show picture 1 ). As the perianal skin becomes inflamed and swollen, extreme pain can develop.

Thrombosed internal hemorrhoids may also cause pain, although usually less severe. Rarely, if there is a reduction of blood supply to an internal hemorrhoid (primarily grade IV disease), the hemorrhoid may become "strangulated". Strangulation can cause extreme pain, and the decreased blood supply can cause tissue death (gangrene). This can be a life-threatening complication and requires immediate surgical treatment.

CAUSES Hemorrhoids are associated with a number of factors (often associated in combination), including the following:

Straining to pass stools
Chronic constipation
Diarrhea
Prolonged sitting
Advancing age
Pregnancy
Pelvic tumors

DIAGNOSIS Hemorrhoids are diagnosed based upon a history, physical examination and visual inspection of the anal canal and rectum. The clinician will visually examine the rectum and anus, and may insert a gloved finger into the rectum.

Despite the fact that bleeding is common in patients with hemorrhoids, other potential causes of bleeding should be excluded. To test for blood that may not be visible, the clinician obtains a small stool sample on a gloved finger. The stool is smeared onto a chemically coated paper and drops of another chemical are added. If blood is present, the color of the paper will change to blue. This is called Hemoccult testing.

To evaluate the size of the hemorrhoids and exclude other possible causes of bleeding, a clinician may recommend a sigmoidoscopy or colonoscopy. Both procedures involve insertion of a lighted instrument to visualize the inside surface of the gastrointestinal tract. The anal canal can also be visualized with anoscopy but anoscopy does not permit inspection of other regions of the colon.

Anoscopy involves examination of the anus and the lower rectum with a short, lighted instrument.

Sigmoidoscopy uses a longer, flexible, lighted viewing tube inserted through the anus, and enables the clinician to directly view the rectum and sigmoid colon (the S-shaped lower region of the large intestine). ( See "Patient information: Flexible sigmoidoscopy" ).

Colonoscopy enables visual examination of the rectum and the major portion of the large intestine (colon) via an elongated, flexible, viewing instrument introduced via the anus. ( See "Patient information: Colonoscopy" ). It is the preferred test in patients who require full examination of the colon (such as those who require colon cancer screening). ( See "Patient information: Screening for colon cancer" ).

CONSERVATIVE TREATMENT Several options are available for the treatment of hemorrhoids. For most patients, conservative or minimally invasive measures are effective in relieving symptoms.

Fiber supplements Increasing fiber in the diet is one of the best ways to soften and bulk the stool, which can help to reduce bleeding from hemorrhoids. Fiber is found in fruits and vegetables. The recommended amount of dietary fiber is 20 to 35 g/day ( show table 1A-1C ).

Most people do not consume an adequate amount of fiber and thus require fiber supplementation. Several supplements are commercially available including psyllium seed (Metamucilÿ), methylcellulose (Citrucelÿ), and calcium polycarbophil (Fiberconÿ). These products work by absorbing water and increasing stool bulk, which increases the frequency of bowel movement and softens stool. Bulk forming laxatives are very safe but side effects may include gas and bloating, especially when they are first started. They may be used alone or in combination with dietary changes, and are safe to use every day. Bulk forming laxatives are not habit forming, and can be used lifelong. ( See "Patient information: Constipation in adults" ).

Laxatives If increasing fiber does not relieve constipation or if side effects of fiber are intolerable, a laxative may be recommended. ( show table 2 ). People are often concerned about the regular use of laxatives, fearing that they will not be able to have a bowel movement when the laxative is stopped. However, there is little to no evidence that laxatives are "addictive" or that using laxatives increases the risk of constipation in the future. Instead, use of laxatives may actually prevent long-term problems with constipation.

Warm sitz baths During a Sitz bath, the rectal area is immersed in warm water for 10 to 15 minutes two to three times daily. Sitz baths are available in most drugstores, and portable bowls are available to use at work or school. It is also possible to use a bathtub by simply filling it with 2 to 3 inches of warm water. It is not recommended to add soap, bubble bath, or other additives to the water. Sitz baths work by improving blood flow and relaxing the internal anal sphincter.

Topical treatments Various creams and suppositories are available to treat hemorrhoids and many are available without a prescription. None has been studied extensively to determine its effectiveness. However, pain-relieving creams and hydrocortisone rectal suppositories may help relieve pain, inflammation, and itching, at least temporarily.

Creams and suppositories, particularly hydrocortisone, should not be used for longer than one week unless directed by a clinician, since they may cause side effects such as skin rash and inflammation (pain-relieving creams) or skin thinning (steroid creams).

Minimally invasive procedures Patients who have bothersome hemorrhoid symptoms, despite trying conservative measures, may consider a minimally invasive procedure. Most procedures are performed as a day surgery, allowing a patient to go home in the afternoon or evening. The following procedures are intended for treatment of internal hemorrhoids.

Rubber band ligation Rubber band ligation is the most widely used procedure, and is best suited for grade I, grade II, and certain grade III internal hemorrhoids. It is successful in approximately 70 to 80 percent of patients.

Rubber bands or rings are placed around the base of an internal hemorrhoid. As the blood supply is restricted, the hemorrhoid shrinks and degenerates over several days. Many patients report a sense of "tightness" after the procedure, which may improve with warm sitz baths. Patients are encouraged to use fiber supplements to avoid constipation.

Delayed bleeding may occur when the rubber band falls off, usually two to four days after the procedure. In some cases, a raw and sore area develops five to seven days following the procedure. Other less common complications of rubber band ligation include severe pain, thrombosis of other hemorrhoids, and localized infection or pus formation (abscess). Rubber band ligation rarely causes serious complications.

Laser, infrared, or bipolar coagulation These methods involve the destruction of internal hemorrhoids with laser or infrared light or heat. Coagulation causes the hemorrhoidal tissue to harden and degenerate, and to form scar tissue as the area heals. Coagulation is generally effective for grade I and grade II internal hemorrhoids, and may have fewer risks of complications than rubber band ligation. However, recurrence rates may be higher than with rubber band ligation.

Sclerotherapy During sclerotherapy, a chemical solution is injected into hemorrhoidal tissue, causing inflammation, degeneration, and scar formation. However, sclerotherapy may be less effective than rubber band ligation.

Thrombosed hemorrhoids Blood clots within external hemorrhoids can cause excruciating pain. Patients who are treated within 48 hours of thrombosis may benefit from surgical removal of the clot (called evacuation), which can be performed in the doctor's office. After 48 hours, the clot may not be easy to remove and has already begun to break down. As a result, patients with thrombosis who are seen after 48 hours are frequently given pain-relieving medications by mouth, analgesic creams, stool softening agents, and warm sitz baths. These measures generally provide adequate relief until the blood clot and associated pain resolve.

After a thrombosed hemorrhoid resolves, patients should undergo sigmoidoscopy or colonoscopy to exclude other underlying anorectal diseases unless they have been performed recently.

Surgery Patients who continue to experience symptoms despite conservative or minimally invasive therapies typically require surgical removal of hemorrhoids (hemorrhoidectomy). Surgery is the treatment of choice for patients with symptomatic grade IV internal hemorrhoids or strangulated internal hemorrhoids.

Hemorrhoidectomy involves the surgical removal of excess hemorrhoidal tissue and anal canal lining. There are various techniques for the operative treatment of hemorrhoids. It is successful in 95 percent of patients. In most cases, general or spinal anesthesia is used.

Most patients experience some degree of pain following hemorrhoidectomy. Some studies have found that certain medications that relax the internal anal sphincter (such as topical diltiazem) or injection of the internal anal sphincter with botulinum toxin (during surgery) may reduce postoperative pain but neither of these approaches is considered routine.

Complications Complications following standard surgical removal of hemorrhoids (called closed hemorrhoidectomy) include the following:

Urinary retention A small percentage (between 2 and 30 percent) of patients have temporary difficulty emptying their bladder

Urinary tract infections Urinary tract infections develop in approximately five percent of patients following hemorrhoidectomy.

Fecal impaction Fecal impaction occurs when a large mass of hardened feces collects in the rectum. This is usually caused by post-operative pain and fear of defecation (passing feces), and can be a side effect of narcotic medication. Most surgeons recommend the use of bulk fiber, stool softeners, and stimulant laxatives to help prevent fecal impaction. However, should it develop, intervention may be required with anesthesia to manually remove the mass.

Delayed bleeding - Bleeding occurs in one to two percent of patients, typically 7 to 16 days following surgery.

Rarely, other complications such as infection and abscess occur, though this happens in less than 1 percent of cases.

SUMMARY

Hemorrhoids are a common problem that develop from dilated veins in the lower rectum. They may be internal (located inside the lower rectum) or external (under the skin around the anus) ( show figure 1 ).

Symptoms include painless bleeding, itching in the anal region, protrusion of an internal hemorrhoid through the anus, pain, and leakage of feces.

Hemorrhoids may be caused by straining to pass stools, chronic constipation, diarrhea, prolonged sitting, advancing age, pregnancy, and (rarely) pelvic tumors.

Hemorrhoids are diagnosed based upon a history, physical examination and visual inspection of the anal canal and rectum. Visual inspection typically involves either an anoscopy, sigmoidoscopy or colonoscopy.

While bleeding is common with hemorrhoids, other potential causes of bleeding should be excluded with one of the tests described above.

Several options are available for the treatment of hemorrhoids. For most patients, conservative or minimally invasive measures are effective in relieving symptoms. Conservative treatment includes fiber supplementation, warm sitz baths, and topical creams or suppositories. Increasing fiber in the diet is one of the best ways to soften and bulk the stool, which can help to reduce bleeding from hemorrhoids. Fiber is found in fruits and vegetables. The recommended amount of dietary fiber is 20 to 35 g/day ( show table 1A-1C ). Most people do not get enough fiber in their diet and thus require a fiber supplement. Several are available in drugstores.

During a Sitz bath, the rectal area is immersed in warm water for 10 to 15 minutes two to three times daily. Sitz baths are available in most drugstores.

Various creams and suppositories are available to treat hemorrhoids and many are available without a prescription. None has been studied extensively to determine its effectiveness. However, pain-relieving creams and hydrocortisone rectal suppositories may help relieve pain, inflammation, and itching, at least temporarily. Creams and suppositories, particularly hydrocortisone, should not be used for longer than one week unless directed by a clinician, since they may cause side effects such as skin rash and inflammation (pain-relieving creams) or skin thinning (steroid creams).

Patients who have bothersome hemorrhoid symptoms, despite trying conservative measures, may consider a minimally invasive procedure, including rubber band ligation, coagulation techniques, and sclerotherapy.

Patients who continue to experience symptoms despite conservative or minimally invasive therapies typically require surgical removal of hemorrhoids (hemorrhoidectomy).