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Hemorrhoids

What are Hemorrhoids?

Hemorrhoids are enlarged or swollen veins in the lower rectum and the anal canal. Hemorrhoids are common, occurring in both men and women. Although hemorrhoids do not usually cause serious health problems, they can be annoying and uncomfortable. Fortunately, treatments for hemorrhoids are available and can usually minimize the bothersome symptoms.
Hemorrhoids that are hidden inside the rectum are called “internal” hemorrhoids. You cannot see them, but they can cause symptoms. Hemorrhoids that you can see or feel are called “external” hemorrhoids.

Causes of Hemorrhoids

There are many different causes of hemorrhoids, but in general they are caused by increased pressure on the veins in the pelvis and rectal area. This is caused by:
  • Chronic constipation or diarrhea, excess straining to have bowel movements is a common cause of hemorrhoids
  • Pregnancy, due to pressure in the pelvis from the baby in the uterus
  • Obesity
  • Prolonged sitting for most of the day (for example truck drivers or other professions that require sitting for most of the day)

Symptoms of Hemorrhoids

The most common symptoms of hemorrhoids can include the following
  • Painless rectal bleeding, usually is a small amount
  • Anal itching or pain, due to irritation of the skin surrounding the anus
  • Tissue bulging around the anus, some people can see or feel hemorrhoids on the outside of the anus
  • Leakage of feces or difficulty cleaning after a bowel movement
Hemorrhoids are more common in people who are older and in those who have diarrhea, pelvic tumors, during or after pregnancy, and in people who sit for prolonged periods of time and/or strain (push hard) to have a bowel movement.
Rectal bleedin gMany people with hemorrhoids notice bright red blood on the stool, in the toilet, or on the toilet tissue after a bowel movement. The amount of blood is usually small. However, even a small amount of blood in the toilet bowl can cause the water to appear bright red, which can be frightening. Less commonly, bleeding can be heavy.

While hemorrhoids are one of the most common reasons for rectal bleeding, there are other, more serious causes. It is not possible to know what is causing rectal bleeding unless you are examined.

You should seek medical attention if you see bleeding after a bowel movement

Pain – Hemorrhoids can become painful. If you develop severe pain, call your healthcare provider immediately because this may be a sign of a serious problem.

Testing for Hemorrhoids

In many cases, your doctor can determine if you have hemorrhoids by asking you about your symptoms and doing a physical examination. Some hemorrhoids are visible on the outside (called External Hemorrhoids) and others are deeper inside (called Internal Hemorrhoids), and these are generally not visible on the outside.

The doctor will likely do a digitial rectal examination (using a gloved finger inside your rectum) or may need to do an Anoscopy (by placing a short, lighted, scope into your anus and examining the inside of the anal canal).

If you have rectal bleeding, the doctor will need to determine where the bleeding is coming from. Many times the bleeding can be from hemorrhoids, but it can also be from other medical conditions such as colon or rectal cancer. You may need to have a Colonoscopy or sigmoidoscopy for further testing.

Types of Hemorrhoids

External hemorrhoids are those that are visible on the outside of the anus; they originate in the lower part of the anus. These can become inflamed and the blood inside the veins can become clotted. This is called Thrombosed (or clotted) Hemorrhoids.
Internal Hemorrhoids are generally not visible on the outside because they originate higher up in the anal canal. Internal hemorrhoids more commonly cause bleeding after a bowel movement, in comparison to external hemorrhoids. If internal hemorrhoids become large and severe, they can push out through the anus and may be visible. This can be very painful, especially if the hemorrhoids become trapped by the anal muscle and cannot go back inside.
Classification of Internal Hemorrhoids:
  • Grade 1(minor): present but only visualized by a doctor with anoscopy or colonoscopy, and do not extend out the anus
  • Grade 2: can extend out of the anus with a bowel movement or with straining, but will go back inside spontaneously
  • Grade 3: extend out of the anus with a bowel movement or with straining, but will not go back inside spontaneously, and requires the patient to manually push it back inside. If you have this, you should seek medical attention, but it is not urgent.
  • Grade 4 (severe): extend outside the anus and are not able to be pushed manually back inside.
**If you have this, you should seek medical attention immediately as this can cause significant complications

Nonsurgical Treatment for Hemorrhoids

One of the most important steps in treating hemorrhoids is avoiding constipation (hard or infrequent stools). Hard stools can lead to rectal bleeding and/or a tear in the anus, called an anal fissure. In addition, pushing and straining to move your bowels can worsen existing hemorrhoids and increase the risk of developing new hemorrhoids.

Fiber supplements-Increasing fiber in your diet is one of the best ways to soften your stools. Fiber is found in fruits and vegetables. The recommended amount of dietary fiber is 20 to 35 grams per day

Several fiber supplements are available, including psyllium (Konsyl; Metamucil; Perdiem), methylcellulose (Citrucel), calcium polycarbophil (FiberCon; Fiber-Lax; Mitrolan), and wheat dextrin (Benefiber). Start with a small amount and increase slowly to avoid side effects.

Laxatives – If increasing fiber does not relieve your constipation, or if side effects of fiber are intolerable, you can try a laxative.

Many people worry about taking laxatives regularly, fearing that they will not be able to have a bowel movement if the laxative is stopped. Laxatives are not “addictive” and using laxatives does not increase your risk of constipation in the future. Instead, using a laxative may actually prevent long-term problems with constipation.

Warm sitz baths – During a sitz bath, you soak the rectal area in warm water for 10 to 15 minutes two to three times daily. Sitz bath tubs are available in most drugstores. It is also possible to use a bathtub and sit in 2 to 3 inches of warm water. Do not add soap, bubble bath, or other additives in the water. Sitz baths work by improving blood flow and relaxing the muscle around the anus, called the internal anal sphincter.

Topical treatments – Various creams and suppositories are available to treat hemorrhoids, and many are available without a prescription. Pain-relieving creams and hydrocortisone rectal suppositories may help relieve pain, inflammation, and itching, at least temporarily.

You should not use hemorrhoid creams and suppositories, particularly hydrocortisone, for longer than one week, unless your healthcare provider approves.

Minimally Invasive Treatment Options

If you have bothersome hemorrhoids after using conservative measures, you may want to consider a minimally invasive procedure. Most procedures are performed as a day surgery. The following procedures are intended for treatment of internal hemorrhoids.
Rubber band ligation – Rubber band ligation is the most widely used procedure to treat hemorrhoids. It is successful in approximately 70 to 80 percent of patients. Rubber bands or rings are placed around the base of an internal hemorrhoid. As the blood supply is restricted, the hemorrhoid shrinks and degenerates over several days. Many patients report a sense of “tightness” after the procedure, which may improve with warm sitz baths. Patients are encouraged to use fiber supplements to avoid constipation.
Delayed bleeding may occur when the rubber band falls off, usually two to four days after the procedure. In some cases, a raw and sore area develops five to seven days following the procedure. Other less common complications of rubber band ligation include severe pain, thrombosis of other hemorrhoids, and localized infection or pus formation (abscess). Rubber band ligation rarely causes serious complications.
Laser, infrared, or bipolar coagulation – These methods involve the use of laser or infrared light or heat to destroy internal hemorrhoids.

Sclerotherapy – During sclerotherapy, a chemical solution is injected into hemorrhoidal tissue, causing the tissue to break down and form a scar. Sclerotherapy may be less effective than rubber band ligation

Surgical Treatment of Hemorrhoids

If you continue to have hemorrhoids despite conservative or minimally invasive therapies, you may require surgical removal of hemorrhoids (hemorrhoidectomy). Surgery is the treatment of choice for patients with large internal hemorrhoids.

Hemorrhoidectomy involves surgically removing excess hemorrhoidal tissue. This can be done in various ways, but it is generally done under general anesthesia with the patient asleep. It is successful in 95 percent of patients.

Risks of Hemorrhoid Surgery include (but not limited to):

  • Bleeding, may be immediate or delayed several days after the surgery
  • Constipation, due to pain in rectal area and due to narcotic pain medication
  • Injury to the anal sphincter, which could result in anal incontinence
  • Anal stricture (narrowing of the anus due to scar tissue)

After Hemorrhoid Surgery:

This is generally a same-day surgery. Most people are able to return to work and other activities in about 1-2 weeks. You may have a small amount of bleeding on the dressing or after having a bowel movement; this can last for a couple weeks. You should contact your doctor if the bleeding is more than a few Tablespoons per day.

You may resume your usual diet immediately after surgery.

**It is very important to not allow yourself to become constipated after surgery.**
  • To avoid constipation or stool impaction, we recommend starting a high fiber diet the morning after surgery (Bran cereal, wheat or rye bread, fresh fruits, and vegetables) and also one tablespoon of Metamucil (or other fiber supplement powder) mixed with 8 ounces of water each morning and evening starting the day after surgery.
  • You should take Dulcolax stool softener (Docusate is the generic name) 100mg tablet twice daily starting on the day before your surgery, and until you are no longer taking pain medication.
  • If you go 48 hours without a bowel movement (BM), you should take 2 tablespoons of Milk of Magnesia every 6 hours until your first BM, and then stop.
  • Call the office if you go more than 2 days without a BM or if you are having abdominal pain or abdominal distension.
  • Drink plenty of water and juice and eat fresh fruits and vegetables.

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