Internal hemorrhoids (piles)

What is a hemorrhoid?

A hemorrhoid is a bundle of vascular tissue consisting of a network of small veins and small arteries located in the anal canal. Hemorrhoids are present in the anal canal of every person from birth.

The presence of a hemorrhoid is not a disease.

Normally, a hemorrhoid does not hurt.

The function of hemorrhoids is not fully understood. It helps in continence issues. With age, the muscles of the pelvic floor weaken, as does the anal sphincter. When the muscles weaken, the hemorrhoids help to seal off the anal canal and help to keep the continence.

Over time in geriatric patients, the contribution of hemorrhoids to continence can reach 15-20%.

It is called a disease or pathology when hemorrhoids become symptomatic:

– Bleeding

– Anal pain

– Urge to defecate (pressing sensation in the anus)

– Hemorrhoids appear outside the anal canal (prolaps).

Bleeding

Bright red, non-painful bleeding, especially after bowel movements. Blood may be visible on the toilet bowl or toilet paper.

Additional tests may be prescribed to rule out inflammatory bowel disease or colorectal cancer.

Any patient with anal bleeding should undergo a colonoscopy to rule out a tumor:

• If there is a family history of cancer and in particular colon cancer.
• Patients with black stools (old blood) and changing stools will be advised to undergo a colonoscopy.
• Blood loss accompanied by change in the frequency of bowel movements.
• Blood loss accompanied by abdominal pain.
• If older than 40 years
• If chronic blood loss.

Prolaps

• Protrusion of hemorrhoids outside the anal canal due to squeezing during defecation.
• Sensation of urge to pass stools (Tenesmus: (false urge,)
• Due to the swelling of the hemorrhoids in the anal canal, the patient feels pressure in the anal canal and may have a false urge to defecate.

It is not exactly understood why hemorrhoids become symptomatic. Several factors contribute to the development of symptoms.

• With age, the connective tissue becomes looser and weaker.  This can cause the hemorrhoids to swell and slide into the anal canal, sometimes beyond the anus (prolapse).
• As a result of sphincter hypertonia (high tension in the sphincter) of the anus, the hemorrhoids are pushed through the tight sphincter when squeezing and have difficulty getting back into the anal canal through the same tight sphincter. The blood flowing back from the hemorrhoids will be hampered  flowing through the tight sphincter and the hemorrhoids will gradually swell and increase in volume.
• When the interconnections widen in the network of veins and arteries, the increased blood supply causes swelling of the hemorrhoids.

Haas Pa The pathogenesis of hémorroïds Dis Colon Rectum 1984; 27 :442

Arabi Y Anal pressures in hemorrroids and anal fissure Am J Surg 1977;134:608

Morinaga K, A novel therapy for internat hemorroïds: Ligation of the hemorrhoidal artery with a newly devises instrument in conjunction with a Doppler flowmeter. Am J Gastroenterol 1995;90:610

• Yes, it is estimated that between 4 and 36% of the population will be affected by symptoms.
• Symptoms are most frequent between the ages of 45 and 65 years.
• Symptoms are rarely present before the age of 20. Men and women are affected equally.

(Thomson WH Nature of haemorroïds Br J Surg 1975;62: 542 -552)

• Pregnancy
• Constipation
• Chronic cough
• Increased intra-abdominal pressure/tension (pelvic tumor, fluid in the abdomen)
• Hereditary factors

Stage I

Hemorrhoids do not descend from the anal canal, but may bleed.

The patient is examined in the lateral or gynecological position.

– Inspection and palpation of the perineum (region around the anus)

– Rectal / anal palpation

– Anuscopy

No, hemorrhoids are not a risk factor for developing cancer.

Additional tests may be prescribed to rule out inflammatory bowel disease or colorectal cancer.

Any patient with anal bleeding should undergo a colonoscopy to rule out a tumor:

• If there is a family history of cancer and in particular colon cancer.
• Patients with black stools (old blood) and changing stools will be advised to undergo a colonoscopy.
• Blood loss accompanied by change in the frequency of bowel movements.
• Blood loss accompanied by abdominal pain.
• If older than 40 years
• If chronic blood loss.
• Anyone with known inflammatory bowel disease who has not had a recent colonoscopy (within 3 years).

Should you always treat hemorrhoids (piles)?

Internal and external hemorrhoids are not dangerous.

Treatment depends on the discomfort and the amount of blood loss the patient experiences.

If there are no significant symptoms for the patient, a wait-and-see approach may be justified.

Conservative treatment

Conservative treatment aims to stabilize the symptoms of hemorrhoids or reduce acute episodes. However,  conservative treatment will not make the hemorrhoids go away.

• High-fibre diet (+ fibre supplement)
• Regular bowel movements: prevent episodes of constipation and prolonged straining on the toilet.
• Mild warm – hot sitting bath: Water 40-42°C, for 5-10 minutes, The aim of the sitting bath is to relax the internal sphincter muscle, allowing the protruded hemorrhoids to return into the anal canal.
• Medication: Flavonoids (Daflon…) enhances the venous drainage and thus can potentially relief  symptoms of hemorrhoids.
• Ointments : Most ointments contain corticosteroids that temporarily reduce the swelling of the hemorrhoids. (Scheriproct®, Trianal®….)

Banding of hemorrhoids (piles)

Banding of a hemorrhoid consists of aspiration of the hemorrhoid within an instrument to enable the placement of a rubber band at the base of the hemorrhoid. The rubber band will strangle the hemorrhoid and cause it to partially die, reducing its volume and the risk of bleeding

See surgical procedure: hemorrhoid banding

Sclerotherapy of hemorrhoids (piles)

The treatment of hemorrhoids with sclerotherapy involves injecting a product into the hemorrhoids that clog up and seal the blood vessels in the hemorrhoid, reducing its volume and also reducing the risk of bleeding.

See surgical procedure: sclerotherapy of hemorrhoids

Classic hemorrhoidal resection (Milligan-Morgan hemorrhoidectomy)

During a hemorrhoidectomy, one or more of the hemorrhoids (piles) are removed under general/loco-regional anesthesia.

See surgical procedure: hemorrhoid (pile) resection / hemorrhoidectomy

Anopexy, suspension of hemorrhoids (piles) (hemorrhoidopexy according to Longo)

When performing a hemorrhoidopexy (according to Longo), the hemorrhoids are pulled up into the anal canal under general/loco-regional anesthesia, so that they no longer bulge out during bowel movements.

See surgical procedure : Hemorrhoidopexy

Radio frequency / laser treatment of hemorrhoids

A radio frequency or laser fibre is inserted at the base of hemorrhoids. The heat from the fibre will destroy and seal blood vessels of the hemorrhoidal package, shrink the hemorrhoids in volume and reduce the risk of bleeding.

See surgical procedure: Radiofrequence ablation of hemorrhoids