HAEMORRHOIDS

Haemorrhoids (also known as Piles) are enlarged and dilated (varicose) veins in and around the rectum and anus. Haemorrhoids are very common in men and women. About half of the population above the age of forty suffers from one form or another of haemorrhoids.

Haemorrhoids common in pregnant women are due to foetal pressure in the abdomen or hormonal changes causing the haemorrhoidal veins to enlarge. These veins are also placed under severe pressure during childbirth. However, haemorrhoids caused by pregnancy are temporary for most women.

There are two types of haemorrhoids: Internal and External.

External haemorrhoids are enlarged and dilated veins occurring below the anal sphincter and protrude at the anus. Sometimes these external haemorrhoids may become clotted (thrombosis) causing severe pain and inflammation. When irritated, these external haemorrhoids can itch and/or bleed.

Internal haemorrhoids occur above the anal sphincter, but you cannot feel or see them. The first visible sign of internal haemorrhoids is noticing small bright red blood on your toilet tissue or in the toilet bowl after straining from passing stool. Straining can occasionally push an internal haemorrhoid through the anal sphincter, causing a prolapsed. This is known as a protruding haemorrhoid and can becomes irritated and painful or even bleed. Internal haemorrhoids usually do not cause discomfort, but you may experience a feeling of fullness in the rectum following a bowel movement.

What are the causes of Haemorrhoids

Haemorrhoids are very common and not usually dangerous. There are several common sources of pressure that can be associated with the development of haemorrhoids including:

· Constipation- (extra straining to pass stool)
· Diarrhoea- (frequency)
· Pregnancy and childbirth
· Heavy lifting
· Sitting or standing for long period of time

Diagnosis

If the haemorrhoids are painful and bleed a lot, the doctor should be consulted. The doctor will be able to evaluate and diagnose the condition properly. Bleeding per rectum may also be a symptom of other digestive diseases such as:

· Polyps (Colon or rectal growths)
· Colorectal cancer
· Anal fissure (tear in the lining of the rectum)
· Anal fistula
· Diverticular disease (small sacs or pouches forming in the lining of the large intestine
· Rectal prolapse
· Inflammation of the lining of the rectum (proctitis)

The doctor will be able to examine the rectum and anus visually and manually with a lubricated gloved-finger to determine any abnormalities. If this test is inconclusive a further examination can be performed with a proctoscope or a sigmoidoscope to look into the rectum and sigmoid colon. If the trouble is further up the colon and not related to haemorrhoids, a colonoscopy can be performed using a flexible fibre-optic colonoscope to diagnose the condition.

Treatment

In mild cases of discomfort, creams and ointments bought over the counter can be used to soothe and relieve the symptoms. Soaking in a warm bath or applying ice pack frequently can be helpful in relieving the symptoms. Suppository containing hydrocortisone can also be used to relieve the symptoms. Although these self-help measures can help to relieve the symptoms, they won't make the haemorrhoids disappear altogether. If the haemorrhoids are painful and cause a lot of discomfort, other means of treatment are required, such as:

· Banding of haemorrhoids. A small tight rubber band is placed over the haemorrhoid at the base severing the blood circulation, causing the haemorrhoid to wither away and drop off.
· Injection of haemorrhoids. An oily solution of phenol is injected directly in the haemorrhoids to shrink the blood vessels thus causing the haemorrhoids to wither.

· Stapling of haemorrhoids. This technique was devise in the early 90's and is still not commonly used yet. A special circular stapling device is used to cut the prolapse anal mucosa membrane from inside the rectum. The prolapse tissue is pulled into the device that allows the excessive tissue to be removed while the haemorrhoidal tissue is stapled.

· Haemorrhoidectomy. The traditional surgery.
In a certain percentage of cases, however, surgical procedures are necessary to provide satisfactory, long-term relief. In cases involving a greater degree of prolapse, a variety of operative techniques are employed to address the problem.

Milligan-Morgan Technique.
Developed in the United Kingdom by Drs. Milligan and Morgan, in 1937. The three major haemorrhoidal vessels are excised. In order to avoid stenosis, three pear-shaped incisions are left open, separated by skin bridges and mucosa. This technique is the most popular method, and is considered the gold standard by which most other surgical haemorrhoidectomy techniques are compared.

Ferguson Technique.
Developed in the United States by Dr. Ferguson, in 1952. This is a modification of the Milligan-Morgan technique (above), whereby the incisions are totally or partially closed with absorbable running suture. Due to the high rate of suture breakage at bowel movement, the Ferguson technique brings no advantages in term of wound healing.

Complications of Haemorrhoid Surgery

Early Complications Include:

1. Severe postoperative pain, lasting 2-3 weeks. This is mainly due to incisions of the anus, and ligation of the vascular pedicles.
2. Wound infections are uncommon after haemorrhoid surgery. Abscess occurs in less than 1% of cases. Severe necrotizing infections are rare.
3. Postoperative bleeding.
4. Swelling of the skin bridges.
5. Major short-term incontinence.
6. Difficult urination. Possibly secondary to occult urinary retention, urinary tract infection develops in approximately 5% of patients after anorectal surgery. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study).

Late Complications Include:

1. Anal stenosis.
2. Formation of skin tags.
3. Recurrence.
4. Anal fissure.
5. Minor incontinence.
6. Faecal impaction after a haemorrhoidectomy is associated with postoperative pain and narcotic use. Most surgeons recommend stimulant laxatives, or stool softeners to prevent this problem. Removal of the impaction under anaesthesia may be required.
7. Delayed haemorrhage, probably due to sloughing of the vascular pedicle, develops in 1 to 2 percent of patients. It usually occurs 7 to 16 days postoperatively. No specific treatment is effective for preventing this complication, which usually requires a return to the operating room for one or more stitches.