Hemorrhoids; A Disease No One Talks About
“ The Lord will smite the with the botch of Egypt and with the “emerods”….Deut 28:27 KJV
I quote the above Old Testament scripture to verify the historical verification of “emerods” or hemorrhoidal disease. This confirms that this dreaded condition has been upon this planet for centuries and is not necessarily a disease of this “new age”.
What are hemorrhoids?
Hemorrhoids can be defined in a couple of different ways. The “not so clinical definition” is they are merely varicose veins located in the anorectum. I must admit that this definition does allow the physician to explain this condition in a way that is understandable to the patient, however, the previously stated definition is an oversimplification. A more recent study has described the presence in the anal canal/lower rectum of specialized highly vascular “cushions” or “pads” consisting of discrete masses of thick submucosa which contain blood vessels, smooth muscle and elastic and connective tissue. It is suggested that hemorrhoids are nothing more than sliding downward of this part of the anal canal lining. Such cushions are present in everyone, and it is suggested that the term “hemorrhoids” be confined to situations where these cushions are abnormal (enlarged, inflamed) and cause symptoms. The cushions or pads are located in three constant sites; right anterior, right posterior, and left lateral, and upon examination, this is where the examiner will see the presence of hemorrhoidal disease. This is also called the “Surgical Y”.
How common is hemorrhoids?
It is a well known fact that 50% of the adult population over the age of 50 has some degree of hemorrhoidal formation. Approximately 5% of the general population have symptoms of hemorrhoids (bleeding, pain, itching, protrusion). When I teach class, I use the example of being at a Portland Trail Blazer basketball game and there are 20,000 people present; 1000 of those will likely have symptoms related to hemorrhoidal disease. 80% of both sexes will have the symptoms of hemorrhoids at some time in their lives.
What are the causes of hemorrhoids?
Anything that increases the pressure within the hemorrhoidal venous plexus can eventually lead to the formation of hemorrhoids/ prolapsus. You must also remember that the prevalence of this disease is highest in countries with the most affluence. This is probably due to the existence of fiber- depleted diets that lead to constipation and more pressure during the defecatory act on the surrounding venous plexus in the anorectum. Another interesting consideration is the absence of one way leaflet valves in the veins of the portal system; thus any increase in pressure within the portal venous system (liver disease, obesity etc.) will eventually cause an increase in the venous pressure within the pelvic internal hemorrhoidal venous plexus. This result is directly related to the swelling of the anal cushions/ pad and hemorrhoid formation. One factor that must also be considered is the amount of pressure within the internal sphincter muscle. This smooth muscle has receptors, which are sensitive to a variety of chemicals; thus, when a chemical stimulates the alpha-receptors of the internal sphincter muscle, contraction occurs, thus causing a narrowing of the anal canal and/or an overshoot of this muscle when stimulated during the act of defecation. This would explain why the Lord technique or intense anal dilation would be a viable treatment for hemorrhoidal disease. Other factors to consider are the fact that we are upright, and biped and that gravity causes increase intrarectal venous pressure.
Classification of hemorrhoids-
The following allows the proctologist to establish a baseline for the purpose of discussion of this disease with a nomenclature that is consistent.
Internal hemorrhoids; symptomatic, exaggerated submucosal vascular tissue located above the anorectal line and are covered by transitional and columnar (mucosal) epithelium.
1 degree- no protrusion, but may bulge into the anal canal/ may / may not bleed.
2 degree- protrudes at the time of BM, but reduces spontaneously, may/ may not bleed.
3 degree- protrudes at the time of BM, must be manually reduced, may/ may not bleed.
4 degrees- permanent prolapse/ protrusion and cannot be reduced, may/ may not bleed.
External hemorrhoids- dilated venules of the inferior hemorrhoidal venuus plexus located below the anorectal line and covered by squamous/ modified squamous epithelium. There are two different types of external hemorrhoids
a) Non- thrombosed- dilated venules, which do not contain blood clots.
b) Thrombosed- external hemorrhoids which contain blood clots of different sizes, whose symptoms will be determined by the size of said clots. These lessions are very painful and usually appear suddenly, whose duration and severity are determined by their size.
Mixed hemorrhoids- a combination of both internal and external hemorrhoids. Clinically these are hemorrhoids that usually occur in the confines of the anal canal and are covered by modified stratified squamous epithelium.
Strangulated hemorrhoids- these are a combination of both internal and external hemorrhoids, which are characterized by mucosal and anal prolapsus, intense spasms of the internal and external sphincter muscle group, cutting off the blood supply and usually contains multiple blood clots. Because of the vascular abnormality due to the muscle spasm and if allowed to progress, this type of hemorrhoidal disease can progress to become necrotic and gangrenous.
Signs/Symptoms of hemorrhoidal disease-
Bleeding- 75% of all bleeding from the large bowel is caused by hemorrhoidal disease. Bleeding associated with hemorrhoids will be bright red and the amount will be dependent upon the severity of this condition. Anemia is not uncommon and at times hospitalization is necessary due to blood loss.
Pain- one must recall the anatomy of the anorectum when interpreting pain patterns consistent with hemorrhoids. Internal hemorrhoids are usually not painful unless strangulated. When there is pain involved with hemorrhoids it is indicative that the condition originates at or below the anorectal line therefore being consistent with mixed or external hemorrhoidal disease.
Protrusion/ Prolapse- if the hemorrhoidal disease has progressed then there is frequently protrusion, which is most noticeable during defecation. If the protrusion is constant (4 degree hemorrhoids) then mucosal leakage and fecal soiling is more common (wet anus syndrome). This frequently causes persistent pruritus/ itching as a common symptom.
Diagnosis of hemorrhoids-
Care history- usually a patient will have a rich history of this condition, dating back for years prior to consulting a physician. The typical complaints will be the symptoms previously discussed; bleeding, protrusion, slight pain and itching or perianal irritation. Bowel patterns prior treatment OTC medications constitutional diseases such as IBS, ulcerative colitis, Crohn’s disease etc. should all be excluded as possible contributors to this condition and need to be addressed. Dietary history, as it may be related to proper bowel pattern, should be discussed.
Inspection- visual inspection of the external perianal skin is essential is the differential diagnosis of this condition. All types of hemorrhoids (prolapsing internal, mixed, external and strangulated) are readily visible and recognized by the experienced clinician.
Anoscopy- this is the definitive examination to determine the extent of the hemorrhoidal condition. The use of a disposable anoscope (Hinkel-James) is best when performing this procedure, and at times a topical anesthetic may be indicated to reduce discomfort. Mild straining by the patient at times may help assess the amount of prolapse present. Other conditions, such as hypertrophied anal papilla, rectal polyps, anal fissures etc. may also be disclosed.
Proctosigmoidoscopy- this procedure is used to best assess the condition of the rectum and the lower bowel. The flexible sigmoidoscope allows the examiner to readily view the status of the bowel mucosa (Crohns disease, ulcerative colitis, IBS etc.) and exclude or confirm the presence of colorectal cancer.
Treatment of hemorrhoids-
When a diagnosis of hemorrhoids is made and the origin of the bleeding has determined the etiology to be that of hemorrhoids, then the following treatment options may be employed.
Medical- there are lifestyle changes that need to be changed when hemorrhoids are present. It is essential that the patient be aware that straining during the defecatory act be minimized as well as not prolonging this process. Many people make a “library out of the bathroom” causing intense aggravation of any anorectal disease. I recommend a hydrophilic bulk forming agent, (COL-EZE-psyillium based) to soften the stool, and advise to refrain from the use of chemical laxatives (Cascara sagrada, Senna) as dependency may occur. Hot sitz baths (Epsom salts), stool softeners, (COL-EZE) and anal suppositories/ topical soothing agents is the first line of treatment. Dietary changes must be discussed excluding those foods that may irritate (alcohol, spicy foods, coffee, etc.) the hemorrhoidal condition but to include those foods that may add necessary natural bulk to promote normal bowel activity (high fiber). Adequate fluid intake (6-8 glasses of water daily) is necessary to promote proper consistency of the stool.
Rubber band ligation- this is the use of a device called a “Baron’s ligator” where a constricting rubberband is placed around the prolapsing hemorrhoid, restricting its blood flow and constricting the tissue until it becomes necrotic. The “dead” hemorrhoidal tissue sloughs and is replaced by minimal scar tissue. This type of treatment is best for internal hemorrhoids grades 1 degree, 2 degree and early 3 degree. Please note that it can only be for lesions above the anorectal line. The biggest unwanted side effect is pain when the ligator mistakenly includes tissue from the upper canal in the ligated tissue. This eventually will cause possible ulceration, fissure formation and intense sphincter spasms. Another side effect is intense bleeding, to the extent that hospitalization is required. This occurs when the sloughing tissue exposes its arterial supply and the blood loss becomes excessive.
Sclerotherapy- this is the injection of 5% phenol in vegetable oil submucosally above the hemorrhoid. Usually 3-5cc are placed at each hemorrhoid site. This is a procedure that has its origin in Great Britain. It causes fixation, retraction and partial atrophy of the hemorrhoidal disease. It is indicated in 1and 2-degree internal hemorrhoids and is very effective. Possible side effects are scar tissue formation and rectal stricture, which usually occur if there are excess amounts of the phenol and oil solution is injected. It is contra-indicted in patients with ulcerative colitis, leukemia, lymphoma or portal hypertension. For some reason, this technique has lost clinical popularity, and is not readily available.
Cryotherapy- this is the destruction of hemorrhoids by freezing with liquid nitrogen (-180 degree C). This technique had a brief window of popularity, but is no longer clinically popular. I had experience with this procedure and found it not practical, as storage of the liquid nitrogen is difficult and instructions in its use says to apply the “probe” to the tissue until it turns white” and then remove. This is not exact enough for the clinician and the amount of tissue that sloughs is somewhat unpredictable.
Infared Photocoagulation (IRPC)- this is the application of a laser like devise that emits infared light that causes destruction of the diseased tissue. It is applied in bursts of 0.5 to 3 seconds per site and is effective on 1, 2 and 3 degree internal hemorrhoids. Side effects are similar to other treatments; bleeding, pain and rectal stricture. I had extensive experience with this procedure and the biggest problem was equipment failure. The disposable tips were very expensive and the power generator spent more time at the manufacturer that in my office.
Surgical hemorrhoidectomy- this procedure is reserved for the most severe cases of hemorrhoidal disease. When one has internal hemorrhoids 3 or 4 degree and coexistent prolapsus, closed hemorrhoidectomy may be the only option. In my practice it is unusual to see a clinical situation where hemorrhoidectomy is necessary, but when indicated this may be the patients only viable option. The procedure is just a matter of dissecting the diseased tissue from the anal verge up to the anorectal ring and then closing the wound. There are usually 3 incision sites located in the right posterior, right anterior and left lateral quadrants. Bleeding is controlled by electrotherapy and running sutures. Needless to say, this procedure is post-surgically one of the most painful experiences an individual will even endure. Complications are bleeding, intense post-operative pain and scar tissue formation, which may lead to proctostenosis, or a narrowing of the ano-rectal canal. Sometimes the opposite occurs where division or inadvertent muscle/ neurological damage may lead to incontinence or wet anus syndrome. When possible, it is clearly obvious that one should resort to all non-surgical options prior to submitting to surgical hemorrhoidectomy.
Negative galvanic treatment/ “Keesey” treatment- this type of non-surgical treatment is the application of a negative galvanic current by way of a disposable metallic electrode to the diseased hemorrhoidal tissue. It was first discovered by WE Keesey who published an article in 1934 on its clinical application. The negative galvanism causes NaOH (sodium hydroxide) to form at the contact point of the negative electrode, thus causing thrombogenesis and destruction of the hemorrhoidal vascular bed, leading to reduction and removal of internal hemorrhoids. The amount of current is usually somewhere between 15 to 18 Ma for approximately 5-7 minutes per treatment site. The number of treatments is determined by the severity of the hemorrhoidal disease. Treatment may easily be administered on consecutive days with as many as 3 to 4 treatments in a 24-hour period. The typical case with internal hemorrhoids 2-3 degrees may require 8-12 treatments. Side effects include pain and bleeding, but remember that the mucosa is void of somatic sensory enervation allowing this treatment to be administered with little or no discomfort. I have used a variety of the aformationed non-surgical treatments (ligation, IRPC etc.) and the negative galvanic (Keesey) technique is the best tolerated, most effective and has the least likelihood of initiating unwanted side effects (pain, bleeding, infection etc.). In my 37 years of practice at the Sandy Blvd. Rectal Clinic-Portland I have administered approximately 80,000 (Keesey) treatments with few complications and very good outcome. This treatment offers to patient a great alternative to conventional surgical procedures with a predictable outcome that is quite satisfactory.
I hope this brief outline has enlightened the reader to his/her options when addressing annoying hemorrhoidal condition. Please be mindful that there are a myriad of diseases that occur in/ around the anorectum and colon, and proper examination is necessary to make a positive diagnosis. The presence of conditions such as anal fissures, fistula disease, rectal prolapse, pruritus ani (itching), perianal abscess, skin tags, venereal disease (condyloma, herpes, gonorrhea), perianal skin cancer, and colorectal cancer, emphasize the importance of proper diagnosis.