What Are Hemorrhoids?

Hemorrhoids are enlarged veins located in the lower part of the rectum and anus. They become pathological when swollen or inflamed.  This condition can be divided according to its location with relation to the rectum, i.e.  internal and external hemorrhoids which have different presentation and problems.

1. Internal haemorrhoids
   These enlarged veins are located in the inside lining of the rectum. It will present itself with painless bleeding after defecation. Some people may also experience feeling soft bits of tissue protruding through the anus after passing stool. These bits of tissue may disappear spontaneously immediately after passing stool or sometimes need to be reduced manually.
2. External haemorrhoids
   These enlarged veins are located underneath the skin outside the anal verge. It may present itself with symptoms of pain, bleeding, itchiness and swelling on passing stools. Pain can range from minor discomfort or burning to severe pain. Severe pain suggests that there may be a vessel that has been blocked causing thrombosis (blood clots in the vessel)

What Causes Hemorrhoids?

This condition is very common. It can occur at any age but mostly seen in adults above 30 years old and in pregnant women.  It is associated with straining during defecation and constipation. Pregnant women may have this condition because of the pressure of an enlarged uterus and hormonal changes. People who are overweight, who stand too long or doing heavy lifting also may experience this condition. All of these situations cause increased pressure in the haemorrhoidal veins causing them to swell and expand.

When Should I See My Doctor?

Consult your doctor if you notice any bleeding during or after passing motion. The doctor needs to check to make sure that the cause of the bleeding is hemorrhoids and not any other sinister condition such as cancer. Colorectal cancer needs to be ruled out in patients with anal or rectal bleeding who :

• Are more than 40 years old.
• Have a family history of colon cancer or personal history of cancer.
• Have associated abdominal discomfort or pain.
• Have altered bowel habits either frequent diarrhea and /or constipation.
• Have unexplained recent weight loss.

What Can I Do About Hemorrhoids?

Several measures can be taken to avoid hemorrhoids and reduce its symptoms

1. Prevent constipation
   • Have more fiber in your diet such as consuming more fresh fruits, leafy vegetables,  and have whole grain bread and cereal instead of white bread or normal cereal.
   • Increase your fluid intake ideally eight glasses of water.
   • Do regular exercise .
   • Avoid laxatives which can lead to diarrhea and worsen the hemorrhoids. However, bulk-forming (high fiber) laxatives such as Fybogel may be used.
2. Relieving the pain
   • Have warm baths to reduce pain and itchiness
   • If any swelling occurs, use ice packs to reduce it or sit in a warm basin of water added with salt.
   • Take pain-relief medications such as paracetamol, aspirin or ibuprofen to reduce the pain
   • While many topical agents and suppositories are available for the treatment of hemorrhoids, there is little evidence to support their use. It may relieve symptoms but does not improve the underlying disorder and long term use is discouraged due to local irritation of skin.

When Do I Need Surgery?

Usually hemorrhoids may resolve on its own if you avoid or reduce the factors that may precipitate it as mentioned above. However, if hemorrhoids are persistently bothersome, please consult your doctor.

Surgical treatment consists of outpatient and inpatient procedures:

Outpatient procedures:

1. Rubber band ligation may be done to treat internal hemorrhoids. This is a simple office procedure done by placing a small rubber band around the base of the hemorrhoids. This band will stop the blood flow to the area causing the lesion to shrink.
2. Sclerotherapy involves the injection of a sclerosing agent, such as Phenol into the hemorrhoid, causing the vein wall to collapse.

Inpatient procedures:

1. Hemorrhoidectomy is a surgical excision of the hemmorhoid. It requires 2-4 weeks for recovery.
2. Doppler guided transanal hemmorhoidal dearterialization uses Ultrasound to locate the arterial blood flow which are ligated.
3. Stappler hemmorhoidectomy is a procedure involving resecting the lax soft tissue that had allowed the hemorrhoids to prolapse downwards.

Can Hemorrhoids Recur?

Yes, hemorrhoids can recur even after operation or procedures done to treat it. It is important to avoid constipation, straining during passing motion and other associated factors mentioned above.

Hemorrhoids During Pregnancy

Hemorrhoids during pregnancy are not uncommon. It usually occurs during the later stage of pregnancy up until postpartum period. In Malaysia, women may experience higher occurrence of hemorrhoids due to our postpartum cultural practice (‘berpantang’) which includes reducing water intake and avoiding certain fruits and vegetables. In women who have constipation and hemorrhoids it is advisable to be cautious while undergoing this postpartum practice. Consult your doctor if you are experiencing constipation and having symptoms of haemorrhoids.

References

• Pfenninger, J.L., & Zainea, G.G. (2001). Common anorectal conditions: part 1. Symptoms and complaints. American Family Physician, 63(12), 2391-2398. Retrieved 29/4/2011 from http://www.aafp.org
• Davies, R.J. (2006). Hemorrhoids. American Family Physician, 74(7), 1168-1170. Retrieved 29/4/2011 from http://www.aafp.org
• Pray, S.W. (2001). Hemorrhoids: self-care vs. physician care. US Pharmacist, 26(5) posted online 5/01/2001. Retrieved 29/04/2011 from http://www.medscape.com/viewarticle/407642
• Familydoctor.org editorial staff. (2010). Hemorrhoid: reducing pain and discomfort. Retrieved 29/04/2011 from http://familydoctor.org/online/famdocen/home/common/digestive/basics/090.html