Hemorrhoids

Hemorrhoids usually are caused by increased pressure within the lower abdomen

• Hemorrhoids are enlarged and swollen blood vessels located in the lower part of the rectum and the anus. The blood vessels become swollen due to increased pressure within them.
• Hemorrhoids usually are caused by increased pressure within the lower abdomen. Some potential causes include:
  • straining at the time of bowel movement (this may be due to constipation or profuse diarrhea)
  • during pregnancy
  • obesity
  • prolonged sitting
  • rectal cancer
  • anal intercourse
  • inflammatory bowel disease (Crohn's disease and ulcerative colitis)
• Internal hemorrhoids are located on the inside lining of the rectum and cannot be felt unless they prolapse and push through the anus opening causing pain and itching.
• External hemorrhoids are located beneath the skin on the outer aspect of the anus. Symptoms may include bleeding with a bowel movement and a mass or fullness that can be felt at the anal opening.
• A thrombosed external hemorrhoid occurs when blood within the blood vessel clots, and may cause significant pain and swelling.
• External and internal hemorrhoids are diagnosed by a physical exam and history by a health-care professional. Sigmoidoscopy or colonoscopy may be ordered to look for other causes of blood in the stool.
• Several treatments are available for hemorrhoids, and include home remedies, for example, over-the-counter (OTC) medicine like stool softeners and creams or suppositories to shrink and decrease inflammation of the hemorrhoid tissue); changes in the diet; Sitz baths; exercise; or surgery.
• Hemorrhoids can be prevented by keeping the stools soft, by regular exercise, eating a high fiber diet, drinking plenty of fluids; avoiding straining with bowel movements, and trying to avoid sitting for long periods of time, especially on the toilet.

The most common signs and symptom is painless bleeding. There may be bright red blood on the outside of the stools, on the toilet paper, or dripping into the toilet. The bleeding usually is self-limiting.

Prolapse of an internal hemorrhoid occurs when the internal hemorrhoids swell

Most often, internal hemorrhoids have no symptoms but are only found if there is bleeding with a bowel movement or if the hemorrhoid prolapses so that it can be felt outside of the anus. This may lead to itching and pain as well as the bleeding.

Prolapse of an internal hemorrhoid occurs when the internal hemorrhoids swell and extend from their location in the rectum through the anus. A prolapsed internal hemorrhoid:

• Can be felt as a lump outside the anus
• Can be gently pushed back through the anus, this may resolve the location of the hemorrhoid, but does not fix the hemorrhoid itself
• May enlarge and swell even more if it cannot be pushed back
• May become entrapped, which requires more urgent medical attention

Hemorrhoids may also cause anal itching (pruritus ani), and a constant feeling of needing to have a bowel movement (tenesmus).

Internal hemorrhoid severity can be graded:

• Grade I: Prominent blood vessels with no prolapse
• Grade II: Prolapse with bearing down but with spontaneous reduction
• Grade III: Prolapse with bearing down but requiring manual reduction
• Grade IV: Prolapse with inability to manual reduction

External hemorrhoids occur when a blood clot develops in a hemorrhoidal blood vessel

Thrombosed external hemorrhoids are a painful condition. These occurs when a blood clot develops in a hemorrhoidal blood vessel causing swelling and inflammation.

• When a blood clot occurs in a hemorrhoid, the hemorrhoid will become even more swollen. This swelling leads to increased pain.
• The pain is usually worse with bowel movements and may increase with sitting.

A thrombosed external hemorrhoid may resolve on its own; however, this condition often needs medical care. Bleeding with a bowel movement is never normal and should prompt a visit to a health-care professional. While hemorrhoids are the most common cause of bleeding with a bowel movement, there may be other reasons for bleeding including inflammatory bowel disease, infection, and tumors.

• An internal hemorrhoid is a swollen blood vessel that arises from within the rectum above the pectinate line. It causes no symptoms unless there is bleeding with a bowel movement, or if it prolapses and can be felt externally after if protrudes through the anus.
• An external hemorrhoid arises from blood vessels that surround the anus beyond the pectinate line. They do not cause many problems unless they rapidly expand and clot. Usually this clot resolves spontaneously leaving residual skin.
• A thrombosed external hemorrhoid occurs when the blood clot that forms in an external hemorrhoid does not resolve causing increased swelling and pain within the hemorrhoidal tissue.

Internal, external, prolapsed, and thrombosed hemorrhoids

Hemorrhoids are not arteries or veins, but instead are normal blood vessels called sinusoids that are located in the walls that surround the rectum and anus. When the venous pressure within these blood vessels increases, the hemorrhoids swell and dilate, because it is more difficult for blood to empty from them. This leads to the most common symptoms of bleeding and swelling.

Common situations that increase pressure within the hemorrhoidal blood vessels and lead to abnormalities include the following.

• Straining to have a bowel movement. This may be due to constipation or diarrhea.
• Prolonged sitting, including on the toilet
• Lack of exercise
• Low fiber diet
• Obesity
• Pregnancy
• Colon cancers
• Liver disease
• Inflammatory bowel disease
• Anal intercourse
• Spinal cord injury

When to call the doctor

• Bleeding from the rectum or anus is never normal and although hemorrhoids are the most common reason to have blood in the stool, it should be discussed with your primary health-care professional. Other causes of rectal bleeding exist and can be serious. Inflammatory bowel disease and cancers of the colon can present with rectal bleeding. Blood in the stool should never be ignored.
• Medical care should be sought urgently if a person is taking anticoagulation medications such as warfarin (Coumadin), dabigatran (Pradaxa), rivaroxiban (Xarelto), apixaban (Eliquis), clopidogrel (Plavix), prasugrel (Effient) or enoxaparin (Lovenox).
• Individuals who have associated symptoms such as lightheadedness and weakness may have significant blood loss and may require more urgent care.
• Hemorrhoids do not cause abdominal pain; should this pain be present with bleeding, medical care should be sought immediately.
• Prolapsed hemorrhoids that cannot be pushed back through the anus require medical care.
• Thrombosed external hemorrhoids may cause significant pain and medical care may be necessary to remove the clot.

Hemorrhoids are a common problem and most often may be treated by a primary care provider, internist, emergency or urgent care provider. Surgeons may need to operate to remove enlarged or inflamed hemorrhoids.

Diagnosis of hemorrhoids is usually made by history and physical examination by the health-care professional. Inspection of the anus and a digital rectal examination are often performed. Depending upon the situation, past medical history, medications and stability of the patient, treatment may follow with no further testing.

• Internal hemorrhoids may not be diagnosed by physical exam; they may not be able to be felt, even by digital rectal exam.
• Prolapsed internal and external hemorrhoids may be visualized when the health-care professional examines the anus.
• A thrombosed external hemorrhoid can be diagnosed just by looking at it.

If there is concern that significant bleeding has occurred, a complete blood count (CBC) to measure blood hemoglobin and hematocrit levels, and platelet count is obtained. If the patient is on warfarin (Coumadin), a prothrombin time (PT) or INR may be done to measure the blood clotting levels.

There are several natural home remedies, for example warm Sitz baths, dietary changes, stool softeners, and exercise, to treat hemorrhoids. OTC or prescription medicine or surgery may be required to repair the hemorrhoids, for example, rubber band ligation, sclerotherapy, laser therapy, hemorrhoidectomy, and stapled hemorrhoidectomy.

Hemorrhoid symptoms of pain and itching can be treated at home by doing the following.

Warm Sitz Baths

• Sitting in a few inches of warm water three times a day for 15 to 20 minutes may help decrease the inflammation of the hemorrhoids.
• It is important to dry off the anal area completely after each Sitz bath to minimize irritation of the skin surrounding the anus.

Dietary Changes

• Increased fluid intake and dietary fiber (roughage) will decrease the potential for constipation and lessen the pressure on the rectum and anus during a bowel movement, minimizing further swelling, discomfort, and bleeding. Dietary fiber supplements also may help bulk up the stools

Stool Softeners

• Stool softeners may help. A health-care professional or a pharmacist are good resources to discuss their use.

Exercise

• Individuals with hemorrhoids should not sit for long periods of time and may benefit from sitting on an air or rubber donut available at most local pharmacies.
• Exercise is helpful in relieving constipation and in decreasing pressure on the hemorrhoidal veins. Individuals should be encouraged to have a bowel movement as soon as possible after the urge arises and not sit on the toilet for long periods of time. Once that urge passes, stools can become constipated and straining with a bowel movement may occur.

Over-the-Counter (OTC) Medications

• Many creams, ointments, and suppositories are available for symptom relief and may be used for comfort. However, they do not "cure" hemorrhoids. Often they contain a numbing medication or a corticosteroid to decrease inflammation and swelling.

Prolapsed Internal Hemorrhoids Treatment

• Most prolapsed internal hemorrhoids can be pushed back into the anus, but occasionally your health-care professional may need to reduce them by gently pushing them with constant pressure.
• If the hemorrhoids remain swollen and trapped outside the anus and they are not treated, the hemorrhoid tissue may not receive enough blood and can become infected. In such situations, surgery may be required to resolve the problem.

Thrombosed Hemorrhoids Treatment

• Thrombosed external hemorrhoids can be painful and are associated with a hard lump that is felt at the anus and cannot be pushed back inside. Most often the clot within the hemorrhoid will need to be removed with a small incision.
• After local anesthetic is placed under the skin surrounding the hemorrhoid, a scalpel is used to cut into the area and the clot is removed. There is almost instant relief of the sharp pain but a dull ache may continue.
• There may be some mild bleeding from the hemorrhoid for a couple of days. Sitz baths and over-the-counter pain medications may be recommended.
• The use of a rubber or air rubber donut may help with the pain, and preventing constipation is a priority.

Internal Hemorrhoid Treatment

Unless there is bleeding an internal hemorrhoid may have no symptoms. Once there is bleeding and/or prolapse and the diagnosis is made, home remedies are most often used to control symptoms. If bleeding increases or there is difficulty in reducing prolapsed hemorrhoids, referral to a surgeon is often made to discuss more aggressive treatment options.

External Hemorrhoid Treatment

Treatment of external hemorrhoids usually addresses the hygiene issue, where excess skin tags makes it difficult to properly clean the anus area after a bowel movement. If this becomes a significant issue, surgery can be considered to remove the hemorrhoid.

Thrombosed external hemorrhoids may require the clot removed acutely in an office or emergency/urgent care department procedure.

A variety of surgical options exist for persistent pain or bleeding.

• Rubber band ligation: Rubber band ligation of internal hemorrhoids can be performed in the doctor's office. The surgeon places a couple of tight rubber bands around the base of the hemorrhoidal vein, which causes it to lose its blood supply. There may be some fullness or discomfort for 1 to 2 days after the procedure, and a minor amount of bleeding may be experienced.
• Sclerotherapy: Sclerotherapy describes a procedure when a chemical is injected into the hemorrhoid, which causes it to scar and decrease in size.
• Laser therapy: Laser therapy can be used to scar and harden internal hemorrhoids.
• Hemorrhoidectomy: Hemorrhoidectomy is a surgical procedure performed in the operating room with an anesthetic agent (general, spinal or local with sedation) where the whole hemorrhoid is removed (ectomy=removal). This is the most aggressive approach and there is a markedly decreased chance of the hemorrhoids returning. There is a potential for complications with this procedure; however, these occur less than 5% of the time. Complications include infection, bleeding, and stenosis where scarring causes the anus to narrow.
• Stapled hemorrhoidectomy: Stapled hemorrhoidectomy is the newest surgical technique for treating hemorrhoids, and it has rapidly become the treatment of choice for severe hemorrhoid disease. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids, but instead tightens the abnormally lax hemorrhoidal supporting tissue to prevent the hemorrhoid to prolapse downward. Stapled hemorrhoidectomy is faster than traditional hemorrhoidectomy, taking approximately 30 minutes. It is associated with much less pain than traditional hemorrhoidectomy and patients usually return to normal activities and work sooner.

Regardless of the surgery, Sitz baths and dietary suggestions for increased roughage are usually recommended.

Picture of Internal Hemorrhoids in Anal Canal

Picture of Hollow Tube Inserted into the Anal Canal and Pushing up the Hemorrhoids

Picture of Suturing the Anal Canal Through the Hollow Tube

Picture of Bringing Expanded Hemorrhoidal Supporting Tissue into the Hollow Tube by Pulling on Suture

Picture of Hemorrhoids Pulled Back Above Anal Canal After Stapling and Removal of Hemorrhoidal Supporting Tissue

The following are pictures of the stapled hemorrhoidectomy procedure.

• Picture of Hollow Tube Inserted into the Anal Canal and Pushing up the Hemorrhoids
• Picture of Internal Hemorrhoids in Anal Canal
• Picture of Suturing the Anal Canal Through the Hollow Tube
• Picture of Bringing Expanded Hemorrhoidal Supporting Tissue into the Hollow Tube by Pulling on Suture
• Picture of Hemorrhoids Pulled Back Above Anal Canal After Stapling and Removal of Hemorrhoidal Supporting Tissue

Warm Sitz baths, plenty of fluids and increased roughage are usually recommended. Hemorrhoidal pain is usually managed with over-the-counter pain relievers.

Stool softeners may be recommended by your health-care professional. The person should contact their health care professional if they develop increased rectal pain, bleeding, fever, abdominal pain, or vomiting after hemorrhoid treatment.

The risk of hemorrhoids can be decreased by preventing constipation by eating a high fiber diet, staying well hydrated, getting regular exercise, and trying to have a bowel movement as soon as possible after the urge arises.

Most people with hemorrhoids have an excellent prognosis. While symptoms of bleeding or discomfort may flare up from time to time, they don't last long and can be relieved with symptomatic care at home.