Hemorrhoids: causes, symptoms, treatment and complications

Hemorrhoids, also known as piles, are the blood vessels located in the walls of anus and rectum. Hemorrhoids are a part of normal human anatomy and they are located at the point where arteries merge with veins. One thing that should be noted here is that although hemorrhoids are a part of normal human anatomy, but most of the people and care professionals refer to them as an abnormal finding. That’s because hemorrhoids remain undetected until they swell and cause pain.

Hemorrhoid swelling or piles occur when the pressure of blood in these vessels increase. This increase in pressure leads to the swelling of blood vessels followed by their engorgement with blood. Hemorrhoids can be anatomically divided into external and internal hemorrhoids. To understand this classification, we first need to understand the anatomy of rectum. Rectum can be termed as the terminal part of large intestine that serves to hold feces.

Terminal part of rectum is called anal canal. Anal canal is further divided by a line called pectinate line. This line divides anal canal into an upper 2/3rd part and a lower 1/3rd part. If hemorrhoids develop in the upper 2/3rd part of anal canal these are termed as internal hemorrhoids and if they develop in the lower 1/3rd part they are termed as external hemorrhoids.

Internal hemorrhoids can be further divided into 4 grades:

• Grade 1: These internal hemorrhoids bulge into the anal canal but don’t completely fall into it. These piles don’t protrude out the verge of anus. These swellings may bleed.
• Grade 2: These swelling protrude past the anal verge only when the patient strains during defecation or passing of flatus. But they tend to return to their original position spontaneously without the need on manual pushing.
• Grade 3: These piles protrude past the anal verge when the patient strains during defecation or passing of flatus. But the piles of this grade don’t come back to their original position spontaneously. The patient has to manually push them back inside.
• Grade 4: The piles of this grade remain permanently protruded and don’t retract back. The chances of necrosis or thrombosis are highest in these types of piles. Most of the times these thrombosed hemorrhoids appear as a dark bluish lump present at the verge of anus.

External hemorrhoids can be visualized but internal hemorrhoids remain concealed unless they protrude out of the anus. A non-thrombosed hemorrhoid will appear as a lump of rubber. More than one hemorrhoid swellings can be seen in most of the cases.

Fig.1: Hemorrhoids explained

Causes of hemorrhoids

The exact cause of hemorrhoids is still unclear. But as explained earlier, hemorrhoids develop when there is an increase in the pressure of blood in the vessels. This increase in blood pressure can occur due to a number of reasons:

Low fiber diet

Eating a diet low in fiber is perhaps the most important reason for the development of hemorrhoids. Fiber in diet, which actually comes from fruits and vegetables, adds bulk to the stool. Moreover, this fiber is indigestible by human. The result is softening of stool. But when a person consistently eats a diet poor in fiber, like meat, his stool gets hardened as the result is constipation. Long standing constipation makes a person strain while defecation and this increases the pressure of blood within these blood vessels. When this happens several times; result is swollen, painful and bleeding piles.

Pregnancy

Pregnant females frequently complain of bleeding piles. This happens due to a number of reasons: o Towards the last trimester of pregnancy there is an increase in the blood pressure, called pre-eclempsia or pregnancy induced hypertension. This increase in blood pressure leads to the swelling of blood vessels. o Increasing size of uterus pushes against rectum and the female has to strain more to defecate. Repeated straining increases the pressure of blood in these vessels. o The amount of progesterone increases during pregnancy. It leads to the relaxation of uterus and further complication of constipation and piles.

Abnormal bowel movements

Abnormal bowel movements, both diarrhea and constipation, can lead to the formation of hemorrhoids.

Obesity

Obesity is an important risk factor for this condition because obesity leads to the deposition of fat around the waist line that exerts greater pressure on the intestines and straining during defecation.

Chronic cough

Coughing leads to an increase in the intra-abdominal pressure. This increased pressure subsequently increases the pressure of blood inside these blood vessels.

Miscellaneous factors

A lot of other factors are thought to contribute in the development of bleeding piles. These factors include:

• Hereditary predisposition to develop this condition.
• Dysfunction of the floor of pelvis.
• Prolonged sitting.
• Colon cancer.
• Previous surgery of bowel.
• Constriction of intestine following a surgery.
• Spinal cord injury that leads to bladder and rectal dysfunction.

Symptoms of hemorrhoids

The signs and symptoms associated with hemorrhoids differ according to their position i.e. if they’re external or internal hemorrhoids. These hemorrhoids remain asymptomatic until they swell to such an extent to cause pain and bleeding. Although piles may bleed profusely but anemia due to bleeding piles is very uncommon. Moreover, death due to bleeding piles is a rare occurring.

The signs and symptoms associated with external and internal hemorrhoids are as follows:

External hemorrhoids

These piles can be thrombosed or non-thrombosed. They cause fewer symptoms unless a thrombus develops in them. However, a thrombosed external hemorrhoid can lead to the development of following symptoms:

• The person might come with a complaint of pain, especially during defecation. However, this pain usually lasts for 2-3 days.
• Thrombosed external hemorrhoids are also associated with swelling around the area of anus. This swelling, however, lasts longer as compared to the pain.
• A skin tag might be seen even after the healing of these piles.
• Patients usually complain of itching around anus.
• As these piles become large, they cause problems with hygiene and it becomes difficult for the patients to clean their anal area after defecation.

Internal hemorrhoids

Following are the symptoms that can help distinguish internal hemorrhoids from external ones:

• These hemorrhoids are usually painless.
• Patients come to the doctor when they pass bright red colored blood during or after defecation.
• These piles bleed profusely and the blood usually covers the feces. This condition is known as “hemtochezia”.
• The blood covers the feces but the feces itself is of normal color.
• The patient may pass mucous along with blood.
• Usually these hemorrhoids remain concealed as they’re present inside the body. However, sometimes their size increases and they prolapsed outside and become visible.
• The patients also complaints of itchiness.
• These hemorrhoids are usually painless unlike the external ones. These piles become painful only when they undergo necrosis i.e. the tissues start to die.

Complications of hemorrhoids

The complications of hemorrhoids are usually very rare. Some complications that follow hemorrhoids are as follows:

• The most common complication is pain, mainly during defecation.
• The patients complain of itchiness and irritation around the anal area. Pain and irritation usually alleviate after taking a salt bath.
• One complication is bleeding. This complication is quite disturbing but rarely causes serious complications like anemia.
• Hemorrhoids cause complications associated with hygiene as the anal area become difficult to clean after defecation.
• Poor hygiene around the anal area can lead to several infections.

Treatments of hemorrhoids

As explained earlier, most of the times hemorrhoids remain asymptomatic. The need for treatment arises only when the symptoms appear. Hemorrhoids can be treated in a number of ways.

These ways include:

Home remedies for hemorrhoids

Although, home remedies can’t totally cure this condition but these methods can help reduce the symptoms. This approach of treatment is suitable for the hemorrhoids of grade 1.

Some home remedies include:

• Add small amount of salt in a tub containing hot water (sitz bath). Sitting in this water can help reduce the itching and spam of anal muscles.
• Eat a diet rich in fiber. Add more fruits and vegetables in your diet and stay away from meat products. This will help soften the stool.
• Avoid eating spicy food as this will help reduce the itching and irritation.
• Apply ice packing on the affected area. This will help ease the pain.
• Try not to sit in one position for a long time as it will complicate the symptoms.

Over the counter medications

Several over the counter medications are recommended. These medicines are meant to decrease itching, inflammation and soften the stool. This approach of treatment is suitable for the hemorrhoids of grade 1.

These medicines include:

• Stool softeners: Hardened stool is the most important cause of bleeding piles. So, stool softeners help soften the stool and help it pass through the rectum and anal canal. These medicines achieve this function by increasing the amount of water or fat in the stool. The most commonly prescribed medicines in this group include Colace, Surfak, and Correctal.
• Suppositories and creams: Suppositories and creams are also meant to soften the stool. Some creams and suppositories contain a small amount of topical anesthetic that helps in reducing the pain. Other preparations, like Anusol, contain a small amount of astringent that help to shrink the swollen tissues. Some suppositories contain a small amount of steroids like hydrocortisone that helps reduce the inflammation associated with hemorrhoids.

Non surgical approaches

Grade 2 or grade 3 piles are difficult to treat with over the counter medications or home remedies. You can continue to use these methods of treatment as an adjuvant. To treat the piles of this grade, several methods are used to make the pile harden or shrivel.

Such methods include:

• Choking the pile with a rubber band. It decreases the supply of blood to the piles- making them hard and shrivel. This method is extremely effective and cure rate is as high as 90%.
• Another approach is injecting a sclerosing agent like phenol into the pile. This method is known as “sclerotherapy”. These agents make the walls of the veins to collapse. As the result, the supply of blood to the protruding tissue decrease and ultimately this tissue decreases in size and falls off. The rate of success in this case is as high as 70%.
• When other methods fail, cauterization is used to cause shrinkage of the inflamed area.
• Other methods include use of laser, infrared radiations and cryosurgery to reduce the size of piles.

Surgical approach

When all other methods fail, surgery is the last resort for the treatment of swollen piles. This method is usually employed to treat external hemorrhoid or internal piles of 4th degree.

The surgical approaches for the treatment of piles are as follows:

• Excisional hemorrhoidectomy is a surgical method that is used to get rid of piles only in severe cases. This method is associated with significant post-operative pain and patient usually requires 2-3 weeks to get cured completely.
• Doppler-guided, transanal hemorrhoidal dearterialization is a more sophisticated method that can be used to treat piles. This method uses sound waves to exactly locate the flow of blood within the vessels of hemorrhoid tissues. These blood vessels are then tied. Result is reduction of flow of blood to the tissues and shrinkage of inflamed tissue. This method is better as compared to Excisional hemorrhoidectomy because this method causes significantly less pain and the rate of recovery is a bit fast. This method, however, is a bit more expensive.
• Stapled hemorrhoidectomy is also known Stapled hemorrhoidopexy. This method involves surgical removal of the most, but not all, of the inflamed tissue. The remaining tissue is then repositioned to cover the area of excision. This method is also more effective and is associated with less pain. The rate of recover and healing is also much high. This method is used for used for hemorrhoids of grade 2 and above.