HAEMORRHOIDS

     

Haemorrhoids or "piles" are clusters of engorged vessels (blue) just inside the anus

What are Haemorrhoids (Piles)?
Haemorrhoids are swollen but normally present blood vessels in and around the anus and lower rectum that stretch under pressure, similar to varicose veins in the legs. The increased pressure and swelling may result from straining to move the bowel. Contributing factors include pregnancy, ageing, and chronic constipation or diarrhoea. Haemorrhoids are either inside the anus (internal) or under the skin around the anus (external). Surgeons grade haemorrhoids from grades I - IV:

Grade I - internal always, producing symptoms

Grade II - internal at rest, protrude on straining, recoil inside on their own afterwards

Grade III - internal at rest, protrude on straining, have to be manually put back inside

Grade IV - external at rest OR complicated by thrombosis

  Large external haemorrhoid (Grade 3)

  Circumferential haemorrhoids (Grade 3)

 Thrombosed or "strangulated" haemorrhoids (Grade 4)


What are the symptoms of Haemorrhoids?
Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani) have similar symptoms and are incorrectly referred to as haemorrhoids. Haemorrhoids usually are not dangerous or life threatening. In most cases, haemorrhoidal symptoms will go away within a few days. Although many people have haemorrhoids, not all experience symptoms. The most common symptom of internal haemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal haemorrhoid may protrude through the anus to lie outside the body, becoming irritated and painful. This is
known as a protruding, or prolapsed, haemorrhoid. Symptoms of external haemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external haemorrhoid. In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or
itching, which may produce a vicious cycle of symptoms. Excessive production of mucus may also cause itching. 


How Common are Haemorrhoids?
Haemorrhoids are very common in men and women. About half the population have haemorrhoids by age 50. Haemorrhoids are also common among pregnant women. The pressure of the foetus in the abdomen, as well as hormonal changes, cause the haemorrhoidal vessels to enlarge. These vessels are also placed under severe
pressure during childbirth. For most women, however, haemorrhoids caused by pregnancy are a temporary problem.

 
How are Haemorrhoids Diagnosed?
A thorough history of your symptoms is obtained by your specialist surgeon and an external and an internal examination will be performed. The latter might be a with a gloved, lubricated finger or with short telescopes called proctoscopes or sigmoidoscopes. Occasionally bleeding symptoms have to be evaluated further by partial colon inspections called flexible sigmoidoscopy or by complete colon inspections - typically a colonoscopy - but sometimes radiologically through a barium enema or a CT colonography scan. This is done to exclude more sinister causes of your bleeding i.e. the piles are diagnosed by exclusion of other causes of bleeding.  

What is the Treatment?
Most piles protrude only after bowel evacuation - if they do, you should attempt to return them internally as soon as possible - if they stay outside of the anus they will worsen. If your piles are inflamed or itchy, you could try topical agents to soothe them - these DO NOT STOP BLEEDING OR MAKE PILES GO AWAY, they simply ease your tenderness. Such agents include Anusol, Scheriproct, Ultraproct or PreparationH.

Occasional dampness of the surrounding skin leads to thrush (in which case try an antifungal cream like Clotrimazole "Canesten") or to dermatitis (in which case try a short course of 0.25-1% hydrocortisone cream). Be careful not to clean obsessively with paper or "wet-wipes" as these may exacerbate the irritation.

Specialist treatment takes the form of (1) Bedside treatments or (2) Surgical treatments.

(1) Bedside treatment - these treatments are each designed to interrupt the flow of blood in the vessels taking blood to and from the piles. These include rubber band treatment (akin to docking a lamb's tail), injection sclerotherapy, laser photocoagulation and cryotherapy. These treatments are designed to REDUCE OR ELIMINATE PILE SYMPTOMS, they don't remove the piles. The scientific evidence suggests that they are all equally efficacious in doing so. In this unit you will be only be offered rubber bands, as this is in our view the safest and only reversible method of bedside treatment. It is usually a painless procedure which will be explained in more detail during your consultation.

(2) Surgical Treatments - surgery for haemorrhoids is a straightforward procedure with very little risk, but it is painful in the early post-operative period. It is thus reserved only for those who truly need it, usually after bedside treatments have failed. However, it is usually a decisive step taken to remove the pile and thereby hopefully eliminate your pile symptoms for good. If your piles are singular, or in the usual clusters, you will have a procedure called "Open Ligasure Haemorrhoidectomy". Ligasure is a computer-generated cauterising procedure that eliminates the need for sutures and that seals the wound by glueing the blood vessels closed. This speeds up the procedure and minimises blood loss. If you have circumferential piles, you will be offered a procedure called "Stapled Anopexy or PPH Haemorrhoidectomy". This procedure is a bit more complex, but it is usually painless as it is done higher up in the rectal tube. In this procedure a circumferential cuff of feeding veins and rectal lining is cut out, the piles are drawn upwards and then the circular wound is mechanically closed with titanium staples. Both procedures will be explained to you in great detail by your surgeon.

How are Haemorrhoids Prevented?

  • keep stools soft so they pass easily
  • drink plenty of water each day
  • don't strain and don't sit on the toilet for long!   
  • increase fibre in your diet (fruits, vegetables and whole grains) or with supplements e.g. Fybogel/Ispaghula/Psyllium/Methylcellulose

FISSURES

What is a fissure?

A fissure is a superficial tear or ulcer in the anal skin just inside the anus. These tears usually occur during a bout of straining at stool, but they might occur even with an episode of diarrhoea. Because it is a very sensitive part of the anatomy, these superficial tears cause a great deal of discomfort. Tears typically heal quickly in other parts of the anatomy, but fissures in the anal area seldom heal on their own and become chronic. The correct name for a fissure is “fissure-in-ano”. 

What causes a fissure?


A fissure starts as a superficial fresh tear, but it becomes chronic due to incomplete healing of the wound. Due to its locality, the wound is affected by moisture, by darkness, by lack of ventilation, by lack of rest and by contamination with bacteria. Because the anal skin is so sensitive, pain arising from it leads to reflexive spasm of the anal sphincter muscle. This spasm prevents the circulation of blood to the skin, something you will witness when you clench your fist and notice that your knuckles turn white. Without blood circulation to bring the building materials for the wound to repair itself, healing cannot take place. 

What are the symptoms of a fissure?

Most patients describe painful sharp stinging discomfort on commencing bowel evacuation. As the anus opens up, releasing faeces, sharp pain occurs at the anal opening. A simple analogy is that of a paper cut between your fingers becoming painful when opening the fingers, or athletes foot causing pain between the toes when the toes are separated. This trauma to the cut produces usually bright red fresh bleeding which is separate from the stool and which usually appears on the paper or dripping into the bowl. Following such a painful evacuation, it is common for the anal area to be tender when wiping and some patients report the throbbing pain in the anal canal for a few hours afterwards. The latter is thought to be due to cramp in the anal sphincter. Some patients report pain even when sitting, since the buttocks are pulled apart when sitting. Such patients are often noted to be sitting perched on one buttock cheek. Occasionally the skin surrounding the fissure may become inflamed. This produces a tender hard swelling called an inflamed skin tag or sentinel tag.

What treatments are available?


Treatment of a fissure first requires the patient to undertake measures to facilitate healing. Since most fissures arise from a bout of constipation, it is essential that motions are kept soft and easy to pass. This usually requires a good fluid intake and plenty of fruit and fibre in your diet. If necessary, laxatives should be used to improve this. Should any constipation occur whilst the fissure is being treated, it will put the healing back to the starting point.

Fissure healing will take several weeks due to the adverse circumstances: think how long a superficial cut takes to heal over with normal skin on a part of your body that can be rested, covered with a dressing, kept free of moisture and bacteria and exposed to the drying effects of the air. Two creams are available for fissure healing - GTN 0.2-0.4% and Diltiazem 2%. Both of these creams are designed to relax the spasm in the anal sphincter and to dilate blood channels in small capillaries and arterioles to promote healing. Both creams need to be applied similarly - a small amount of cream is expressed onto the finger (approximately a garden pea-size blob) and this is worked into the skin close to the anal opening. This must be done twice a day for 5 to 6 weeks.

Both Diltiazem and GTN are well tolerated and they seldom produce side-effects. Both creams can cause headaches. If this occurs, try taking some Paracetamol half an hour before applying the cream. If the headaches persist, change over to the alternative cream. You may have better luck with it. Do not expect a big change in your symptoms for at least 4 to 6 weeks. Throughout this time you must continue to keep your bowels working easily and with soft motions. After a course of cream, approximately 70% of patients heal. Of the 30% who do not heal, half will heal if they try the alternative cream for a second six-week course. Unfortunately, 15% of patients who embark on cream therapy will have a persistent fissure and they will need surgical intervention.

Surgery is nowadays a minor procedure. Historically surgeons would have to cut the anal sphincter muscle to weaken it so that spasm could not occur. Instead, we now use a reversible product called Botox to partially weaken the sphincter. Botox is injected into the anal sphincter and causes a partial paralysis of the muscle. The dose that is used is extremely unlikely to have any unwanted side-effects that weaken the sphincter to the point that it doesn’t do its job i.e. leaves you incontinent. The medical literature suggests that temporary loss of control of wind is more likely than loss of control of waste, with an incidence of approximately 2%. However, in many centres the dose used was perhaps too much or the Botox was not injected precisely into the intended part of the anatomy. Even if you were extremely unlucky enough to be affected, it would reverse within approximately 10 weeks and full continence would be restored. We therefore inject the correct dose and injected as accurately as possible by doing this as a quick day case procedure under anaesthetic. I have yet to see a case of incontinence after a decade as a consultant.

Approximately 95% of fissures will heal with Botox therapy. A small number of patients may require a second treatment dose and very rarely do we have to resort to further surgery in which we cut the sphincter (sphincterotomy) or we bring healthy skin into the ulcer area (V-Y flap).