Hemorrhoids are composed of small arteries and veins, of many arteriovenous anastomoses, creating vascular masses. Hemorrhoids are sometimes described as ‘varicose veins’ of the anus. They are located in the lower part of the large intestine (colon) and the anus, in a circular fashion, creating two hemorrhoidal plexuses, the internal and external hemorrhoids. The internal hemorrhoids occur in the lower rectum and the external hemorrhoids develop under the skin around the anus. External hemorrhoids are the most uncomfortable, because the overlying skin becomes irritated and erodes. Therefore, they are present under normal conditions in all people and contribute to the mechanism of continence, i.e. better sealing of the anus and control bowel movements. But when the hemorrhoids become irritated, swollen and inflamed, causing unpleasant symptoms for the patient then we use the term, ‘hemorrhoidal disease’ or ‘hemorrhoidopathy’.
Which are the factors that contribute in the formation of Hemorrhoids?
Hemorrhoids are created progressively. The main factors that contribute in their formation are the following:
- Family history of hemorrhoids
- Chronic constipation or diarrhea
- Unbalanced diet (e.g. low in fiber)
- Aggravating dietary factors (e.g. hot foods, alcohol)
- Sedentary lifestyle
- Prolonged standing
- Inadequate hygiene of the anal area, etc.
Hemorrhoid disease (hemorrhoidopathy) is a completely benign condition, but it affects the patient’s quality of life to a great extent. Hemorrhoidopathy is due to hypertrophy and dilatation of the hemorrhoidal veins, which are located in the lower part of the rectum and the anus. When they develop inside the rectum they are called “internal”, while when they develop under the skin around the anus and are visible with the naked eye they are called “external”.
The symptoms of hemorrhoids usually depend on the type of hemorrhoid.
- Feeling of heaviness and discomfort in the anus with accompanying itching. It goes away with treatment in a few days.
- Thrombosis– Formation of a blood clot inside a hemorrhoidal vein, obstructing blood flow and causing a painful swelling of the anal tissues. This can cause severe and constant pain, which appears suddenly. If the thrombosis concerns an external hemorrhoid, then clinically a purple lesion is detected, which is extremely painful to palpation.
- Bleeding– Painless bleeding during bowel movements. The patient might notice small amounts of bright red blood on the toilet paper or in the stool after a bowel movement. A visual examination by a general surgeon may be enough to diagnose hemorrhoids.However, in some cases, the doctor may order further testing (e.g. rectosigmoidoscopy or colonoscopy) to rule out any other pathological causes that may be responsible for the bleeding.
A rectosigmoidoscopy examines the sigmoid colon and rectum (the last 40 centimeters of the colon), while a colonoscopy explores the entire colon.
- Protrusion (Prolapse) – If the hemorrhoid is protruding (prolapsing) out of the anus, mainly after a bowel movement you may try to gently reposition it inside the anus with your fingers.
CONSERVATIVE TREATMENT OF HEMORRHOIDS
- Changes in diet and lifestyle
- No consumption of alcohol and spices
- Treatment/Avoidance of constipation
- Good hygiene of the anal area
- Use of topical agents and pharmaceutical preparations
NON-SURGICAL HEMORRHOID TREATMENTS (IN A DOCTOR’S OFFICE)
Sclerotherapy– The doctor will inject a chemical solution (sclerosant) into the area around the hemorrhoid, resulting in a scarring reaction which makes the hemorrhoid gradually shrink or shrivel up over time. This treatment is indicated for the mild type of hemorrhoidopathy (1st and 2nd Grade hemorrhoids) and is contraindicated for the external hemorrhoids.
Rubber Band Ligation– Without the use of local anesthesia, the doctor places a small rubber band around the base of the hemorrhoid, cutting off the hemorrhoid’s blood supply. The hemorrhoid typically “withers” and drops off. This treatment is applied to 1st and 2nd Grade Hemorrhoids.
Cryotherapy- The application of very low temperature on the hemorrhoidal nodule results in the destruction of the cell membrane.
Infrared Photocoagulation of Hemorrhoids (IRC) – Infrared Coagulation of Hemorrhoids (IRC) uses infrared light as a heat source to cut off blood supply to internal hemorrhoids, which then causes coagulation of the proteins of the hemorrhoidal tissue, sublimation of the tissues and shrinkage of the hemorrhoids.
Radio frequencies – Direct application on the hemorrhoidal nodule and its immediate destruction.
It should be pointed out that all these treatments should concern formed hemorrhoidal nodules, without mucosal prolapse in order to have the desired results.
SURGICAL HEMORRHOID TREATMENTS
Milligan & Morgan Haemorrhoidectomy – It is also called “open” Haemorrhoidectomy and is highly effective and well tolerated by the patients. It is based on the surgical resection of the three main hemorrhoidal nodules. This surgical procedure has excellent postoperative course and the patient quickly returns to his/her daily activities. Its recurrence rate is around 2% in five years. Open Haemorrhoidectomy requires a general or epidural anesthesia. After surgery, the patient is successfully mobilized and eats on the same day. The patient should stay in hospital for 24 hours.
Haemorrhoidectomy by Longo– It is also called Stapled Haemorrhoidopexy (SH technique). During the procedure, the surgeon uses a circular stapler to cut a cylinder out of the rectal mucosa to eliminate the progression and at the same time creates a series of sutures to unite the tissues. It is applied to patients with hemorrhoids and prolapse of the rectal mucosa. This surgical procedure requires general or epidural anesthesia. The postoperative pain is minimal. After surgery, the patient is successfully mobilized and eats on the same day. He/she needs about a 24-hour hospitalization.
Haemorrhoidal Artery Ligation (HAL) – This operation is based on the theory that the cause of hemorrhoids is the high blood flow in the hemorrhoidal plexuses. With the use of U/S, the vessels are identified and subsequently ligated. This technique does not correct the prolapse of the rectal mucosa. After this surgical procedure, the patient returns to his/her everyday life immediately. The patient should stay in hospital for 24 hours.
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