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What are hemorrhoids?

To understand haemorrhoids and its treatment, one should appreciate certain aspects of the anal anatomy. The lining of the anus can be divided into 2 halves, deep and superficial. The point of division is midway in the anal canal marked by an irregular jagged line known as the dentate line (toothlike projections in the lining, originated from the latin word for teeth, dentatus). Above the dentate line, the lining is the same as that of the rectum. Below the dentate line, the lining is similar to skin.
Above the dentate line, there are 3 anal cushions under the lining. These cushions consist of specialized blood vessels that can rapidly fill up or decompress. This feature allows the anal cushions to prevent leakage of gas or faeces when there is sudden change of pressure, such as when we carry heavy things or when we sneeze. When these anal cushions over-expand (usually due to chronic straining from difficult bowel movement), they can prolapse out of the anus or cause bleeding. This is termed “internal haemorrhoids”.
Below the dentate line, the blood vessels are different from the anal cushions. The blood vessels here are prone to thrombosis (clotting of blood in the vessels) when a person strains very hard such as carrying heavy loads or someone with chronic constipation. The thrombosed vessel appears as a painful hard lump at the edge of the anus. This is termed “external haemorrhoids”.
What is the difference between haemorrhoids and piles?
Haemorrhoids and piles mean the same thing. Haemorrhoids is believed to be derived from the Greek words “haim” and “rhoos” which mean “blood” and “flowing” respectively. Piles is derived from the Latin word “pila” which means round or ball. Both terms are used interchangeably. In medical texts, the term haemorrhoid is preferred.
What are the symptoms?
Based on the description above, there are 3 main symptoms of haemorrhoids; bleeding, prolapse and pain (from thrombosis). Sometimes, one may feel a burning discomfort or itch around the anus and this is due the prolapsed haemorrhoid.
The bleeding pattern seen from haemorrhoids is unique. It is painless and occurs during bowel movement. Some patients notice a splatter of bright red, fresh blood before the faeces. Others describe dripping of fresh blood after the bowel movement. When the faeces comes out, there is usually no blood at all. It is very rare to see blood clots from haemorrhoids because the bleeding stops immediately when the anus closes after bowel movement.
“It is important to note that everyone has anal cushions and therefore, anyone can have some bleeding from haemorrhoids intermittently. This also means that haemorrhoids can co-exist with other diseases of the colon and rectum, such as colon cancer or colon infection (colitis). Please do not ignore your symptoms and see your doctor if the problem persists.”
How can it be treated?
Treatment of haemorrhoids depends on the symptom presented. The aim of treatment is to restore the anal cushions to their normal anatomy and function. The choices available for treatment are numerous and customized based on the patient’s symptoms and severity of haemorrhoids. What is described below is an overview of the available options.
Non-operative treatment
Central to treatment of all patients suffering from haemorrhoids is good dietary and toilet habits. Avoidance of constipation will help alleviate the symptom of bleeding. Having regular bowel movements through a fibre-rich diet and adequate fluid intake will minimize the risk of constipation. Patients are also advised to avoid spending unnecessary time sitting at the toilet. They are advised to use the toilet only when they feel the urge to have a bowel movement and not to go according to a fixed time daily. They should not bring any reading materials into the toilet (this includes gamepads, smartphones and iPads!) either.
If bleeding persists, oral medications are available to stop the bleeding. Small, bleeding haemorrhoids rarely require surgery. If there is itching or burning discomfort around the anus, use of topical creams help soothe the discomfort.
If there is prolapse of haemorrhoids, medication and dietary modification alone cannot adequately treat the problem. An outpatient treatment known as “rubber-band ligation” can be used in conjunction with medication to remove the prolapsed haemorrhoid. A small rubber band (diameter of 2mm) is applied to the base of the prolapsed haemorrhoid after it is reduced back to its original location in the anus. This rubber-band stops blood flow to the tissue and the tissue will shrivel and die. The shriveled tissue drops off and leaves a small ulcer which will heal spontaneously. Up to 3 rubber-bands can be applied at a time and this procedure can be repeated. As the rubber band is applied above the dentate line, the patient usually feels no pain.
Operative treatment
Sometimes, the amount of prolapsed haemorrhoids is too large for the rubber-band technique. Patients with large prolapsed haemorrhoids usually describe a prolapse that can only be reduced back into the anus manually with their fingers. Some are permanently prolapsed and cannot be reduced back into the anus. Patients with large prolapsed haemorrhoids require surgery.
Below are some of the different techniques of surgery for haemorrhoids. The details of the techniques are best left to the doctor to describe to you personally.
Treatment of thrombosed haemorrhoids
In thrombosed haemorrhoids, the treatment is usually for pain. If a patient presents soon after the thrombosis or is in severe pain, the blood clot can be removed in the clinic through a small cut. The release of the clot provides immediate relief. If the patient presents when the thrombosis is several days old, it may be partially resorbed by the body (just like any bruise under the skin) already and treatment is usually with medications to treat the symptoms present. Surgery would not be necessary then. In certain cases, the thrombosis may get infected or show signs to suggest infection. If that is so, surgery is recommended to prevent any secondary infections of the anus.
Do I need any tests before surgery?
The diagnosis of haemorrhoids is made on clinical assessment alone. No further tests are required before surgery. However, if there is a suspicion of a concomitant colorectal problem, a colonoscopy may be required before surgery. In the rare instance that a cancer is detected, the treatment of the cancer takes precedence over the haemorrhoids.
What do I need to look out for after surgery?
Depending on the type of operation done, there can be some variations to your post-operative recovery. There is usually no dietary restriction after surgery. You will have some degree of loss of control to passage of flatus (gas). That will recover when the wounds heal.
After excisional haemorrhoidectomy, the wounds may take up to 4 weeks to heal. There is minimal pain at rest but having a bowel movement can be painful unless oral and topical medications are used. After stapled haemorrhoidectomy, there is a persistent urge to pass motion as the staple line pain feels like having a need for bowel movement. This discomfort usually lasts about 10 days only. For haemorrhoidal artery ligation, the discomfort is the least and last only 2-3 days.
Whichever technique is used for surgery, there is a risk of bleeding which can happen 5-10 days after surgery. This is usually due an infection of the wound or staple line. This bleeding can be easily stopped with an injection into the bleeding site and re-operation is very rarely needed.
As the aim of surgery is to return the anus to its normal function, there is a risk of recurrence of haemorrhoids. This is not a failure of surgery as the normal anal cushions cannot be removed completely. Otherwise, the patient will develop bowel incontinence. Each of the operations can be repeated if necessary but repeat operations are very uncommon within the first 10 years of surgery.
What are the risks if I leave my haemorrhoids alone?
Haemorrhoids are anal cushions that have developed problems and become symptomatic. They do not predispose you to developing colorectal cancer. It is common to see patients who have been diagnosed with prolapsing haemorrhoids who choose to leave it alone once they are sure they do not have colorectal cancer.
Does surgery cure me of piles?
In piles surgery, the guiding principle for surgeons is to restore the anal cushions to their original and ideal position in the upper anal canal. This means that surgery is not aimed at removing ALL of the piles, only to reduce it back to the NORMAL size and location. Removing all of the piles will mean a person can lose bowel control as he/ she may leak stools when coughing or jumping. Therefore surgery will restore normal anal anatomy but there is a small chance of recurrence of piles.
How do I prevent recurrence of haemorrhoids/ piles?
In order to prevent recurrence after treatment of haemorrhoids, you should try to avoid excessive straining during bowel movement as well as bad toilet habits. To avoid straining, you should ensure you drink adequate amounts of fluids daily (at least 1 liter of fluids a day) and avoid constipation. Constipation with hard stools can be overcome by taking more fibre in your diet. Constipation with soft stools will require the aid of laxatives.
Many people have poor toilet habits without realizing it. This includes spending unnecessary time sitting at the toilet such as reading, playing games or smoking. You should avoid at all cost. The other thing to improve is your posture at the toilet. Ideally, one should be sitting forward with your elbows/ hands on your knees with a straight back. This improves effective straining at stools.
If you have feedback or would like to know more about treatment for these conditions, feel free to contact us or make an appointment.