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Haemorrhoids


Haemorrhoids (piles) are swellings that develop from the lining of the anus and lower rectum (back passage). Symptoms range from temporary and mild, to persistent and painful. In many cases, haemorrhoids are small and symptoms settle down without treatment. If required, treatment is usually effective. There are various treatment options, detailed below.

 

What are haemorrhoids and what causes them?


Haemorrhoids are swellings that can occur in the anus and lower rectum (back passage).

There is a network of small veins (blood vessels) within the inside lining of the anus and lower rectum. These veins sometimes become wider and engorged with more blood than usual. These engorged veins and the overlying tissue may then form into one or more small swellings called haemorrhoids.

The exact reason why these changes occur and lead to haemorrhoids forming is not clear. Some haemorrhoids seem to develop for no apparent reason. However, it is thought that the pressure in and around the anus can be a major factor in many cases. If the pressure in and around the anus is increased, then it is thought that this can lead to haemorrhoids developing. Certain situations increase the chance of haemorrhoids developing.

 

What are the symptoms of haemorrhoids?


Internal haemorrhoids

These form in the back passage about 2-4 cm above the rim (opening) of the anus. Their severity and size are classified into grades 1 to 4.

Symptoms can vary. Small haemorrhoids are usually painless. The most common symptom is bleeding after going to the toilet. Larger haemorrhoids may cause a mucus discharge, some pain, irritation, and itch. The discharge may irritate the skin around the anus. You may have a sense of fullness in the anus, or a feeling of not fully emptying your rectum when you go to the toilet.

A possible complication of haemorrhoids that hang down (grade 3-4) is a blood clot (thrombosis) which can form within the haemorrhoid. This is uncommon, but causes intense pain if it occurs.

 

External haemorrhoid (sometimes called a perianal haematoma)

This is less common than internal haemorrhoids. An external haemorrhoid is a small lump that develops on the outside edge of the anus. Many do not cause symptoms. However, if a blood clot forms in the haemorrhoid ('thrombosed external haemorrhoid') it can suddenly become very painful and need urgent treatment. The pain due to a thrombosed external haemorrhoid usually peaks after 48-72 hours, and then gradually goes away over 7-10 days. A thrombosed external haemorrhoid may bleed a little for a few days. It then gradually shrinks to become a small skin-tag.

Some people develop internal and external haemorrhoids at the same time.

 

What is the treatment for haemorrhoids?


Avoid constipation and straining at the toilet

Keep the faeces (sometimes called stools or motions) soft, and don't strain on the toilet. You can do this by the following:

The above measures will often ease symptoms such as bleeding and discomfort. It may be all that you need to treat small and non-prolapsing haemorrhoids (grade 1).

 

Ointments, creams, and suppositories


Various preparations and brands are commonly used. They do not 'cure' haemorrhoids. However, they may ease symptoms such as discomfort and itch.

 

Banding treatment


Banding is a common treatment for grade 2 and 3 haemorrhoids. It may also be done to treat grade 1 haemorrhoids which have not settled with the measures described above (such as an increase in fibre, etc).

This procedure is usually done by a surgeon in an outpatient clinic. A haemorrhoid is grasped by the surgeon with forceps or a suction device. A rubber band is then placed at the base of the haemorrhoid. This cuts off the blood supply to the haemorrhoid which then 'dies' and drops off after a few days. The tissue at the base of the haemorrhoid heals with some scar tissue.

Banding of internal haemorrhoids is usually painless as the base of the haemorrhoid originates above the anal opening - in the very last part of the gut where the gut lining is not sensitive to pain. Up to three haemorrhoids may be treated at one time using this method.

In about 8 in 10 cases, the haemorrhoids are 'cured' by this technique. In about 2 in 10 cases, the haemorrhoids recur at some stage. (However, you can have a further banding treatment if this occurs.) Banding does not work in a small number of cases. Haemorrhoids are less likely to recur after banding if you do not become constipated and do not strain on the toilet (as described above).

A small number of people have complications following banding such as bleeding, urinary problems, or infection or ulcers forming at the site of a treated haemorrhoid.

 

Other treatment options


Banding (described above) is perhaps the most common procedure done to treat haemorrhoids. However, a variety of other surgical procedures are sometimes used. Some surgeons prefer one procedure over another. Your surgeon will advise of the pros and cons of the different procedures. For example, although each procedure is usually successful, as with any surgical procedure, there is some risk that complications or problems may occur during, or following, the procedure.

 

The more commonly done procedures include the following


Injection sclerotherapy Phenol in oil is injected into the tissues at the base of the haemorrhoids. This causes a fibrotic (scarring) reaction which obliterates the blood vessels going to the haemorrhoids. The haemorrhoids then 'die' and drop off similar to after banding. However, this procedure is less widely used than banding because the success rate is not as good.
Various methods that use heat to 'destroy' the haemorrhoids There are various ways this can be done and include: infrared coagulation; photocoagulation; diathermy; electrotherapy. However, these procedures are less widely used than banding because their success rate is not as good.
Haemorrhoidectomy (the traditional operation) An operation to cut away the haemorrhoid(s) is an option to treat grade 4 haemorrhoids, and for grade 2 and 3 haemorrhoids not successfully treated by banding or other methods. The operation is done under general anaesthetic and is usually successful. However, it can be quite painful in the days following the operation.
Stapled haemorrhoidectomy Although the name of this procedure implies that the haemorrhoids are removed (cut out), this is not so. What happens in this procedure is a circular stapling 'gun' is used to cut out a circular section of the lining of the anal canal above the haemorrhoids. This has an effect of pulling the haemorrhoids back up the anal canal. It also has an effect of reducing the blood supply to the haemorrhoids which shrink as a consequence. Because the 'cutting' is actually above the haemorrhoids, it is usually a less painful procedure than the traditional operation to remove the haemorrhoids

 

Haemorrhoidal Artery Ligation


Although still carried out under general anaesthetic, haemorrhoidal artery ligation HALO/THD is an operation with a much shorter recovery time. There are no cuts to the sensitive skin around the anus, which is what causes the severe pain following a traditional open haemorrhoidectomy

A Doppler probe (small ultrasound transducer) is used to visualise the artery that supplies each haemorrhoid with blood and this vessel is surgically tied off internally.

Some people experience a little discomfort in the first couple of days, particularly when opening the bowels, but much less when compared to open surgery. Occasionally, small skin tags are left behind after the haemorrhoids have shrunk, and if troublesome (as is the case for a small proportion of people), these can removed with a second short operation