11 March 2019 Author: Vitor Costa Haemorrhoids are very common. Their prevalence is similar in men and women and is higher between the ages of 45 and 65. Haemorrhoids may be located around the anus (external haemorrhoids) or inside the anus and lower part of the rectum (internal haemorrhoids). It is possible to have both types of haemorrhoids at the same time. Internal haemorrhoids are classified in four grades (I to IV) based on the degree of prolapse (externalisation) through the anus: Grade I haemorrhoids: not prolapsed; Grade II haemorrhoids: prolapsed with spontaneous regression (i.e. return totheir original position); Grade III haemorrhoids: prolapsed, regression only achieved manually; Grade IV haemorrhoids: prolapsed and cannot be repositioned. What causes haemorrhoids? There are a number of causes of haemorrhoids. Known causes include: Constipation, due to straining during bowel movements; Diarrhoea with continuous excretion of soft stools; Standing or sitting for long periods; Obesity; Pregnancy and birth; Hereditary predisposition. Regardless of the cause, the tissue of the rectal and anal walls undergoes substantial stretching . This interferes with their support function and favours dilation of the blood vessels , the walls of which become thinner and change their physiological position. As a result, pressure increases in the haemorrhoid vessels in the rectum and anal canal. The weakened, dilated vessels protrude into the rectum and anal canal. The return circulation in these vessels is compromised and this further encourages their dilatation, venous stasis and the formation of clots. What are the symptoms of haemorrhoids? Haemorrhoids may or may not be associated with symptoms. When there are symptoms, they can differ between external and internal haemorrhoids. Symptoms of external haemorrhoids External haemorrhoids are visible and perceptible in hard and/or dark regions protruding around the anus. The skin covering them is very sensitive and they are therefore usually painful . The pain can become really intense when obstructive clots form (thrombosed haemorrhoids). Damage to the skin covering the haemorrhoids can also result in loss of bright red blood , which may coat stools or toilet paper, or both. Symptoms of internal haemorrhoids Internal haemorrhoids are not visible unless they are prolapsed through the anus. They are normally not painful , unless they are prolapsed and thrombosed. The straining involved in passing stools can also cause lesions and resulting bleeding on the surface of internal haemorrhoids. Grade III and IV internal haemorrhoids may also be associated with faecal incontinence and a mucous discharge that causes anal itching and irritation. Seek medical help in the event of pain and bleeding , even if you think the symptoms are being caused by haemorrhoids. The presence of blood in stools is a symptom common to a number of digestive diseases, such as colorectal cancer. It is therefore very important for it to be investigated by a gastrenterologist or colorectal surgeon for a correct diagnosis and effective treatment. Do not try to self-diagnose or self-medicate. How are haemorrhoids diagnosed? In addition to the patient’s history and a physical examination , the other procedures needed to diagnose haemorrhoids also depend on whether they are external or internal. External haemorrhoids can be diagnosed by observation alone . If they are not prolapsed, diagnosis of internal haemorrhoids involves a rectal examination, though it may not be conclusive. In this case, it may necessary to perform one of the following examinations: Anoscopy; Proctoscopy; Sigmoidoscopy; Colonoscopy. Some of these exams can also rule out other causes of symptoms, such as the presence of blood in the stools. How are haemorrhoids treated? Gastroenterologists and general surgeons can help treat this disease. Acute attacks with severe pain and many large lumps around the anus are normally episodic and, regardless of their severity, are due to thrombosed haemorrhoids. In thrombosed haemorrhoids your physician will more often choose to remove the haemorrhoid containing the clot with a small incision . This small outpatient procedure is performed under local anaesthesia and permanently solves the episode. Outside acute attacks, small external haemorrhoids with mild symptoms are treated to reduce straining during bowel movements by producing softer, better formed stools. Trauma to the lining of the anal canal will also be reduced, which lowers the likelihood of bleeding. Treatment, therefore, mostly includes changes to diet to one with a higher fibre intake (fruit, vegetables and whole grains) and non-alcoholic fluids. Irritation and itching can also be relieved by baths and ointment. Symptomatic haemorrhoids that do not clear up with the above treatments and larger internal haemorrhoids with frequent or permanent prolapse require special instrumental or surgical treatment. Instrumental and often also surgical treatment can be performed as outpatient procedures. The instrumental haemorrhoid treatments: Banding; Sclerosis; Clotting with laser or infrared light; Cryotherapy. Treating haemorrhoids with banding Banding is a treatment that has shown good results for Grade I to III internal haemorrhoids , mainly in patient with comorbilities and high surgical risk. A small elastic band is placed at the base of the haemorrhoid to cut off its blood supply and cause necrosis . The haemorrhoid falls off at the elastic after a few days and the wound will heal within one to two weeks. Treatment by sclerosis Sclerosis treatment involves a local injection into haemorrhoids of a sclerosing product that interferes with the haemorrhoid’s blood vessels causing its necrosis . It is used mainly in grade I and II internal haemorrhoids as an alternative to banding, though it is not as effective. Surgical treatment Surgical treatment is normally reserved for: Patients for whom instrumental procedures have been unable to solve the problem (relieving pain, itching, bleeding, clots and associated infections); Patients who have severe external and internal haemorrhoids in which the anal and rectal anatomy is severely altered or as a front-line treatment of choice for Grade IV haemorrhoids; The surgical procedures most often used to treat haemorrhoids are circular stapled rectal mucosectomy and haemorrhoidectomy, recently with laser. Mucosectomy Circular rectal mucosectomy involves excision of anal mucosa, thereby reducing the prolapse. This technique offers a high cure rate and its main advantages are: It substantially reduces post-operative pain; It considerably reduces convalescence, with a faster return to normal life. Haemorrhoidectomy Haemorrhoidectomy is surgical removal of haemorrhoids . It is still the most effective treatment for a long-term cure. The excess tissue causing bleeding and prolapse is removed in a haemorrhoidectomy. The procedure is performed under general or local (epidural or spinal) anaesthetic. Depending on the circumstances, a short period in hospital may be necessary, normally lasting no more than 24 hours. A variable period of bed rest is also necessary. Laser haemorrhoidectomy is one of the most recent techniques. In this innovative surgery the photocoagulation of hemorrhoids is performed, leading to a significant reduction of it and thus eliminating complaints. This in an outpatient procedure, in which the patient pain is reduced in the postoperative period, allowing a quick return to daily life. How can I prevent haemorrhoids? Prevention involves avoiding pressure on the anal vessels and tissue. The most important measures include avoiding straining when passing stools. To do this, it is particularly advantageous to increase high-fibre foods and non-alcoholic fluids in your diet. This will: Soften stools; Increase their volume; Form them; Facilitate bowel movements. If an increase in fibre and fluid intake does not achieve this effect, you can consider the use of special supplements / medications. Measures to avoid constipation and straining during bowel movements are particularly important in pregnant women. It is also important not to resists the urge to empty your bowels. In other words, go to the toilet as soon as you feel the need. Physical activity can also help to compensate for long periods spent sitting or standing. Meet the general surgery team from Hospital da Luz network. The content published in the Health Guide is intended for the general public and is provided for informational and educational purposes only. It does not replace individual medical assessment, diagnosis, or personalized clinical advice from a qualified healthcare professional. The content is produced or reviewed by physicians and other healthcare professionals at Hospital da Luz and is based on the knowledge available at the time of publication or the most recent update, as indicated at the beginning of each item.
