טחורים – Hemorrhoids
In this article I will address a very common problem which is ” a pain in the rear” called – hemorrhoids. There is a specific mention of Hemorrhoids in the Bible to the area of Beit Shemesh, Israel (where I live); I will address this topic in another article.
Hemorrhoids are part of normal anatomy, all people have hemorrhoidal tissue. In a minority of people hemorrhoids become enlarged or symptomatic. Hemorrhoidal tissue lies within the anal canal and perianal area and consists of blood vessels, connective tissue, and a small amount of muscle
There are two main types of hemorrhoids: internal and external. Internal hemorrhoids are covered with a lining called mucosa that is not sensitive to touch, pain, stretch, and temperature, while external hemorrhoids are covered by skin that is very sensitive. When problems develop, these two types of hemorrhoids can have very different symptoms and treatments.
Some people will develop symptoms attributable to their hemorrhoids and only a small fraction of those patients will require surgical treatment. Patients may experience symptoms caused by either internal or external hemorrhoids or both.
The majority of patients with anal symptoms seen in a colon and rectal surgeon’s office complain of their hemorrhoids but a careful history and examination by an experienced physician is necessary to make a correct diagnosis. Some patients will have long-standing complaints that are not attributable to hemorrhoidal disease. Other serious diseases such as anal and colorectal cancer should be ruled out by a colorectal surgeon or a gastroenterologist.
Painless rectal bleeding or prolapse of anal tissue is often associated with symptomatic internal hemorrhoids. Prolapse is hemorrhoidal tissue coming from the inside that can often be felt on the outside of the anus when wiping or having a bowel movement. This tissue often goes back inside spontaneously or can be pushed back internally by the patient. The symptoms tend to progress slowly over a long time and are often intermittent
Internal hemorrhoids are classified by their degree of prolapse, which helps determine management
Grade 1: No prolapse
Grade 2: Prolapse that goes back in on its own
Grade 3: Prolapse that must be pushed back in by the patient
Grade 4: Prolapse that cannot be pushed back in by the patient
Bleeding attributed to internal hemorrhoids is usually bright red and can be quite brisk. It may be found on wiping, dripping into the toilet bowl, or streaked on the BM itself. Not all patients with symptomatic internal hemorrhoids will have significant bleeding. Instead, prolapse may be the main or only symptom. Prolapsing tissue may result in significant irritation and itching around the anus. Patients may also complain of mucus discharge, difficulty with cleaning themselves after a BM, or a sense that their stool is “stuck” at the anus with BMs. Patients without significant symptoms from internal hemorrhoids do not require treatment based on their appearance alone.
Symptomatic external hemorrhoids often present as a bluish–colored painful lump just outside the anus and they tend to occur spontaneously and may have been preceded by an unusual amount of straining. The skin overlying the outside of the anus is usually firmly attached to the underlying tissues. If a blood clot or thrombosis develops in this area, the pressure goes up rapidly in these tissues often causing pain. This is called a thrombosed external hemorrhoid. The pain is usually constant and can be severe. Occasionally the elevated pressure in the thrombosed external hemorrhoid results in breakdown of the overlying skin and the clotted blood begins leaking out. Patients may also complain of intermittent swelling, pressure and discomfort, related to external hemorrhoids which are not thrombosed
Patients often complain of painless, soft tissue felt on the outside of the anus. These can be the residual effect of a previous problem with an external hemorrhoid. The blood clot stretches out the overlying skin and remains stretched out after the blood clot is absorbed by the body, thereby leaving a skin tag. Other times, patients will have skin tags without an obvious preceding event. Skin tags will occasionally bother patients by interfering with their ability to clean the anus following a BM, while others just don’t like the way they look. Usually, nothing is done to treat them beyond reassurance. However, surgical removal is an option.
The majority of factors thought to produce symptomatic hemorrhoids are associated with an increased pressure within the abdomen that gets transmitted to the anal region. Some of these factors include: straining at stool, constipation, diarrhea, pregnancy, and irregular bowel patterns. It seems that, over time, these factors may contribute to the prolapse of internal hemorrhoidal tissue or thrombosis of external hemorrhoidal tissue.
There are a wide variety of treatment options available for symptomatic internal hemorrhoids depending upon their grade and the severity of symptoms. I would recommend only using techniques that are recognized and recommended by the American Society of Colon and Rectal Surgeons (ASCRS).
Therapy always starts with dietary changes. The main changes consist of increasing dietary fiber to 30 grams daily and drinking two liters of fluid daily.
Rubber band ligation
In the office, rubber band ligation can be used for Grades 1, 2, and Grade 3 internal hemorrhoids. At the time of the examination a ligator device is placed through an anoscope, the ligator can pull up the redundant internal hemorrhoidal tissue and place a rubber band at its base. The band acts to cut off the hemorrhoid’s blood supply and it falls off (with the band) at roughly 5-7 days, at which time you may notice a small amount of bleeding. Rubber band ligation can be associated with a dull ache or feeling of pressure lasting 1-3 days. If symptoms return, repeat banding can be considered. Hemorrhoidectomy is always an option if significant progress is not made with banding. Complications are very uncommon, but may include bleeding, pain and infection.
Also in the office setting, an external thrombosed hemorrhoid can be treated. It involves the injection of a local anesthetic and excising the hemorrhoidal tissue. The pain associated with a symptomatic, thrombosed external hemorrhoid often peaks about 48-72 hours after its onset and is largely resolved after 4-5 days. Pain is the indication to treat a thrombosed external hemorrhoid. If pain is improving significantly, then non-operative measures are used. It is important to note that the entire hemorrhoid must be removed and not “lanced”, as that can be associated with the hemorrhoidal skin sealing over and a recurrent thrombosis (blood clot) developing.
External hemorrhoids, which are not thrombosed, are generally managed with dietary management and topical agents. Only occasionally are they removed surgically.
Most patients respond to non-operative treatment and do not require a surgical procedure. Hemorrhoidectomy, or surgical removal of the hemorrhoidal tissue, may be considered if a patient presents with symptomatic large external hemorrhoids, combined internal and external hemorrhoids, and/or grade 3-4 prolapse. Hemorrhoidectomy is highly effective in achieving relief of symptoms and it is uncommon to have any significant recurrence. However, it also causes much more pain and disability than office procedures and has somewhat more complications.
Hemorrhoidectomy may be done using a variety of different techniques and instruments to remove the hemorrhoids. The excess hemorrhoidal tissue is removed and the resultant wound may be left open. Hemorrhoidectomy is performed in an operating room under anesthesia. All operative procedures for hemorrhoidal disease carry their own set of risks and benefits.
My preference is to use the Ligasure device. Evidence has shown less operative pain compared the classical operation. This is probably due to the fact that no sutures are necessary. The device cut the tissue and seals the blood vessels, making a nearly bloodless and quick operation.
HAL ( Hemorrhoidal Artery Ligation) – Doppler
The HAL procedure is ideal for patients who do not want surgical excision of their hemorrhoids. This method is indicated for treating low to medium grade hemorrhoids. The ligations reduce the arterial blood supply causing the hemorrhoidal cushions to shrink back to normal size. In this manner the HAL method is effective in treating the symptoms of hemorrhoidal disease
Over 100,000 patients have been treated using the HAL procedure worldwide. The main symptoms which HAL treats are bleeding, itching, and pain. Compared to surgical hemorroidectomy there is less pain, no cutting or open wounds and quicker recovery and return to work.
Most patients are satisfied with the results and would ask for the procedure again if necessary. In addition, the HAL procedure has fewer complications and less pain compared to conventional hemorrhoidectomy.
There are 2 procedures which I do not recommend. The PPH stapler (procedure for prolapsing hemorrhoids) is an attractive option since there is usually less postoperative pain. However patients must be aware of the potential complications unique to this procedure. In women there is a risk of a rectovaginal fistula, low risk but possible. Another major issue is PPH postoperative pain, which is when some patients have pain for years after the procedure, for which there is no known solution.
Recently, in Israel, I have been asked about laser surgery for hemorrhoidal disease. As of now, there is no laser technique for hemorrhoids described in the colorectal textbooks or listed as an option by the American Society of Colon and Rectal Surgeons.
Arie Pelta MD FACS FASCRS