Hemorrhoids, also known as piles, are swollen veins in the lower part of the rectum and anus, When the walls of these vessels are stretched, the may become painful, bleed or become irritated.
They have been noted as a common human affliction from the dawn of history. The exact incidence in the population of developing countries has not been determined but the condition is frequently encountered in most of them. Symptomatic haemorrhoids occur in over 4% of the general population.
Causes of hemorrhoids
Varicose dilatation of the internal haemorrhoidal plexus is usually regarded as the cause of internal haemorrhoids. Physiological dilatation, present already in infancy, is presumed to develop into varicosities under the influence of a wide range of factors .
The predisposing factors include heredity, age, sex,pregnancy, the puerperal state and even temperament. The precipitating factors comprise cathartic abuse, diarrhoea, enemata, constipation, infection, anal spasm or atony of the anal sphincter, obesity and rise in intra-abdominal pressure.
Internal hemorrhoids: First-to Fourth Degree
Hemorrhoids can be internal or external. But clinically, piles are graded in degrees.
A first-degree internal hemorrhoids bulges into the anal canal during bowel movement.
A second -degree internal hemorrhoid bulges from the anus during bowel movements, then goes back inside itself.
A third-degree internal hemorrhoid bulges from the anus during bowel movements and must be pushed back in with the fingers.
A fourth-degree hemorrhoid protrudes from the anus all the time.
symptoms and signs
Most patients with anal conditions complain of “piles” regardless of what anorectal symptoms they have . The cardinal symptom in patients with haemorrhoids is, however, the passage of bright red blood, usually unmixed with the stool and varying from mere streaks on the stool or toilet tissue to spurts amounting to appreciable losses of blood . This may lead to
profound secondary anaemia; in men, haemorrhoids are the commonest cause of anaemia. Bleeding is the hallmark of first degree, haemorrhoids and it may, be, accompanied by anal discomfort or irritation.
With the appearance of prolapse on defaecation, mucoid discharge and peri-anal irritation progressively increase; mucoid discharge is at its worst in the third degree stage and leads to much soiling of the underclothing. Pain as a symptom of haemorrhoids occurs only in an acute attack of prolapse, with thrombosis, congestion and oedema and is largely due to spasm of the sphincter.
Asymptomatic haemorrhoids require no treatment but constipation and catharsis which lead to straining at stools, should be avoided. Patients with constipation should be advisedto take high fibre diet, at least 3 litres of fluids a day and open their bowels at a regular time. Supplementation with methylcellulose may be necessary for a while. During an acute attack of haemorrhoids, relief may be obtained by the use of suppositories and rectal antiseptic ointments but these agents are of no curative value.
Treatment of acute attack
The prolapsed hemorrhoids should be replaced in the canal if they are reducible by gentle digital pressure after application of a local anaesthetic cream.
Lying down with the foot end of the bed elevated and local application of cold compresses or decongesting agents help to keep the haemorrhoids reduced.
Topical nitroglycerine also helps to reduce pain. Sedation with diazepam is usually adequate; when the acute reaction has subsided warm Sitz-baths are comforting.
The vogue for operative treatment of acute haemorrhoids by haemorrhoidectomy appears to be abating probably because of the emergence of simpler methods for the treatment of haemorrhoids in general and in particular because a proportion of patients achieve spontaneous cure after an acute attack.
Short of radical operative therapy there are 3 treatment modalities that can be carried out on an outpatient basis -sclerotherapy, rubber band ligation and cryosurgery.
This involves the injection of an irritant sclerosant solution submucosally in the areolar tissue surrounding the internal haemorrhoids. The fibrosis, which follows the chemical inflammation, leads to obliteration of the varicose vein and helps to fix the loose redundant mucous membrane to the inner muscle layer and thereby prevent prolapse. This form of treatment is suitable for 1st degree and small second degree haemorrhoids. It is particularly suitable when bleeding is the only problem. Five per cent phenol in almond or arachis oil is the most frequently used as a sclerosing agent. The sclerosis is induced by the oil base, the phenol serving an antiseptic role.
Sclerotherapy has the advantages of being simple, quick and quite painless if performed correctly. If the method is reserved for the treatment of first and acute second degree haemorrhoids a cure rate as high as 75% may be achieved.
Complications are few: they include infection, sloughing of mucosa from blanching, acute prostatitis and sensitivity to the sclerosant. If the appropriate technique is used such events occur sparingly.
Rubber band ligation
By this method, a rubber band is placed around the base of the haemorrhoids using a special “gun”. This is a suitable means of treating first and second degree haemorrhoids in the absence of the external haemorrhoidal component or anal tags.
Necrosis(dying off of the tied hemorrhoids) may be expected to supervene in 24-48hours; this may be expedited by injection into the banded hemorrhoid of about 2ml of 1% lignocaine which also relieves the slight discomfort which may accompany hemorrhoidal banding. To avoid circumferential ulceration of the anal canal, perhaps not more than 2 haemorrhoids should be banded at any particular time. The results of rubber banding are reported as excellent in nearly 70 % of patients and a further 25 % of patients are improved.
Minor degrees of secondary haemorrhage tend to occur between the 6th and 7th day but severe hemorrhage requiring admission is seen only rarely.
Combined tripple sclerotherapy and rubber band ligation has been shown to be an effective treatment for prolapsing haemorrhoids, with low rates of recurrence or complications.
Rapid freezing followed by rapid thawing destroys cellular membrane; this leads to necrosis of circumscribed areas of tissues. This technique is now being applied to the treatment of haemorrhoids. Using liquid nitrogen, temperatures of -160 DC can be readily achieved and at this level almost immediate anaesthesia is produced so that the procedure is quite painless.
As originally designed, the cryoprobe is placed on each haemorrhoid and freezing carried out for about 3 minutes. An ice ball forms as a visible white area which delineates the area which will slough eventually. Bleeding seldom occurs.
The main drawbacks of the method are the considerable post-operative oedema, albeit painless, and the profuse discharge starting within a few hours and continuing for upwards of 4 weeks. This may require the use of 2-4 surgical pads per day for about 2-3 weeks.
More recently a combination of cryosurgery and banding has been advocated. The bands are first positioned to interrupt the blood supply and limit the area necrosed by subsequent application of the cryoprobe. The procedure is completely painless and the bands are removed soon afterwards. Superior results are claimed for the combination.
This new technique is being used in pilot studies of 1st and 2nd degree haemorrhoids. Applied to the base of the haemorrhoids through a proctoscope, a circular burn about 2mm deep is produced. The results are similar to those of rubber banding, sclerotherapy and cryosurgery; but the procedure is less painful and complications fewer.
Stasis of blood occurs at the vascular plexuses of the prolapsed anal cushions and this leads to acute bleeding of internal hemorrhoids. Stasis activates white cells to release inflammatory mediators which cause an inflammatory response with increased permeability, fragility and necrosis of the vessel wall. Passage of stools easily injures the anal
cushions leading to bleeding.
Flavonoid compounds (Daflon 500-hesperidin in combination with diosmin) suppress bleeding by increasing venous tone and venous return, decreasing stasis and capillary hyperpermeability, inhibiting inflammatory mediators and improving lymphatic drainage. Daflon 500mg causes rapid cessation of bleeding and prevents its relapse. To control bleeding, three tablets of Daflon 500 are taken orally after lunch and dinner for 4 days and then two daily for the next three days .
To prevent relapse, two tablets are taken daily. The bleeding may also be managed effectively by three-day local application of micromized purified flavonoids (MPF).
A recent meta-analysis has raised questions about the apparent beneficial effects of flavonoids in the treatment of haemorrhoids.
This is the method of choice for the management of third degree haemorrhoids particularly those associated with skin tags and external haemorrhoids. Several methods have been described for achieving complete excision of the haemorrhoids but it would appear that the dissection and ligation method remains the most widely practiced operation. Classically this operation entails a 7-10 day hospital stay; specialized centres have, however, recently developed protocols in the daysurgery setting (7 -24hours hospital stay) with improvement of both cost and effectiveness.
Common complications of hemorrhoidectomy are: bleeding, infection, anal incontinence, anal tags, anal stenosis, and anal fissure. These complications are rare if the surgery is well performed.
Hemorrhoidectomy (pile surgery) cost about N150,000 to N200,000 thousand in Nigeria.
(1) Principles and Practice of Surgery by Badoe