Hemorrhoids and Hemorrhoid Treatment
Hemorrhoids are the most common diagnosis referred to Dr. McConnell at the McConnell Colorectal Center.
This is a good thing.
It is important to recognize that hemorrhoids are a normal part of the body, but they can act up at times.
It is also very important to recognize that the majority of people who present with colon rectal or anal cancer thought they had hemorrhoids.
Important point - If you have hemorrhoids and they are bothering you seek treatment from a colon and rectal surgeon who can tell if the hemorrhoids are really hemorrhoids or if they really are a cancer.
When you visit our clinic at the clinic appointment the hemorrhoids will be visualized with the help of a digital rectal exam and anoscopy so that the diagnosis of anal canal cancer can be excluded. If the bleeding has been persistent and is not any better after two months, then it is time for a colonoscopy to exclude colon or rectal cancer.
Dr. McConnell has an outpatient surgical center available for use 24 hours a day where the colonoscopy can be performed quickly and simply.
Dr. McConnell treats hemorrhoids, performs anoscopies and colonoscopies, and can identify the precursors to cancer as well as the cancer itself.
Hemorrhoids may be telling you something, particularly if the problem has been present for some time and has not gone away. Think about any part of your body that you might injure. If there is a problem and it is not gone in two months with over the counter treatments it is time to seek an opinion from someone trained to take care of the anus.
Hemorrhoids or hemorrhoidal cushions are normal part of the body
Anatomically they are known as hemorrhoidal cushions. Cushion is a good term. The hemorrhoids cushion the stool just prior to the arrival into the anal canal for delivery to the outside world.
There are three hemorrhoidal cushions, the right anterior, the right posterior and the left lateral. Think about it anatomically. You are born with five fingers on each hand and they each have a specific name like thumb, index or pointer.
But it is also important to remember you may have two hands but you only have one exit strategy.
Hemorrhoidal cushions (aka hemorrhoids) are important for two reasons:
1. Hemorrhoids provide continence to gas
2. Hemorrhoids allow you to distinguish between gas or stool.
The hemorrhoids therefore mechanically obstruct or cushion the flow of gas through a closed sphincter and provide sensation. If hemorrhoids were absent one would not be able to hold gas and one would not be able to recognize if gas or stool was coming through the anus.
Hemorrhoids are very socially appropriate.
Please note that the hemorrhoids only recognize “stool or gas” not diarrhea. Diarrhea is not recognized by the hemorrhoids. This is very important because the body serves a protective function. Diarrhea is not recognized as “a normal” by the body and particularly by the anus. Therefore a human body and more specifically the anus is incontinent of diarrhea. This is a very important concept to understand. The majority of people who come complain of incontinence are not incontinent. Rather they have diarrhea.
If you would like to read about diarrhea there is another article I have written about diarrhea.
Getting back to the hemorrhoids they are rather important structures mechanically and socially, wouldn’t you agree?
Hemorrhoids swell predominantly because of diarrhea. Chronic diarrhea it is recognized as abnormal by the anus. Over time the hemorrhoids will get larger to prevent the diarrhea from leaking out. As the hemorrhoids swell eventually they get large enough that they will fall out of the anus. When hemorrhoids begin to fall out of the anus this is a significant change from normal. If they fall out and go back in on their own they are grade 2. If they have to be inserted or pushed back into the anus they are grade 3. If they can not be pushed back in they are grade 4.
Acute swelling of hemorrhoids can occur after diarrhea from a food borne illness, after delivery during child birth, or after taking too many laxatives for constipation.
The hemorrhoidal swelling will resolve completely if you can get the stools to normal. Once the stools are normal in two months the anus will return back to normal.
Sometimes this acute swelling of hemorrhoids also involves a blood clot. These can and should be treated immediately.
The blood clot within the hemorrhoidal cushion can emerge from the anus as a blue colored growth from the anus. The thrombosis is usually abrupt and rapidly growing. The mass that appears emerges to its maximum diameter in as little as one hour or over a 24 hour period. Once the mass emerges it is firm and blue. The evacuation of this thrombosis by the colorectal surgeon can decrease the healing time from 2 months to 2-4 weeks if the clot is removed within 72 hours of the clot or mass appearance.
If the clot is left alone and nothing is done it can do one of two things in the majority of cases. It can spontaneously drain in 7-10 days through the skin if the skin is very thin or made very thin by the use of topical steroids. Alternately the clot will undergo liquifactive necrosis which means the clot will turn into liquid and be reabsorbed by the body. The swelling that occurs as a result of the inflammatory process that occurs over the subsequent days after the thrombosis occurs will take 2 months to resolve. This inflammatory process becomes less pronounced if the clot is evacuated within 72 hours of the clots occurrence.
The hemorrhoids serve a protective function to the anal canal. When the hemorrhoids swell they swell internally above a junction between two tissue planes, the mucous of the rectum and the skin of the anus. This plane in this area of the body is called the dentate line. The dentate line is analogues to the lips on the human face. The oral mucousa is separated from the skin of the face by the lips. But unlike the lips the dentate line is a non uniform line, looking more like teeth. The line is a wavy line, much like the pleats of a curtain hitting the edge of a stage. The pockets can be prominent in some people and these appear as pockets. This is sometimes called cryptoglandular disease when the pocket is so deep that the diarrhea which at time can be explosive travels through the pocket or crypt and exits the pocket creating a local inflammation and abscess, called a perianal or perirectal abscess.
The anus is remarkable in that it is most innovative for healing and protecting the body from stool. It has to be, as the contents of stool can be lethal to the body. The body was therefore designed to have the highest amount of blood flow to this area more than any other area of the body. There are five arteries that supply the anus. This provides the oxygen and nutrients necessary for healing. Injuries to the anus can heal rather rapidly if normality is returned meaning the diarrhea is stopped and normal stools are again emerging through the anal canal.
The hemorrhoids serve as the guardians of this innovation. The hemorrhoids are positioned above the dentate line and mechanically if the diarrhea is coming down the curtain at a rapid speed the hemorrhoids serve as a bump at the bottom of the curtain so the diarrhea would not hit the stage or the dentate line or the crypts. The course or direction of the diarrhea would be diverted serving a protective function.
When operating on hemorrhoid and removing them from the anal canal it is important to open the pits or the crypts to prevent future abscess or fistula formation.
Clearly the hemorrhoids are a remarkable part of the body serving very specific and critical functions for the body's health and survival. Socially, physically and anatomically.
Preservation of hemorrhoidal cushions should be a top priority. Stool which is too soft or too hard harms the anus. The hemorrhoid trys to cushion the stool and prevent it from harming the anus, but it is not always successful. So the goal should always be to have a normal healthy well formed stool.
Two very important things make a normal stool - plants aka methylcellulose and probiotics aka bacteria.
Methylcellulose and bacteria serve to make the stool of the correct form to allow it to pass out of the body with sufficient form to protect the anus from harm.
Bacteria is stored in the appendix just in case the colony of live bacteria is washed out by a flood (diarrhea), destroyed by pesticides (antibiotics) or is decimated by an overgrowth of a virulent strain of bacteria. The appendix houses more than 50 trillion bacteria which then repopulates after the carnage. Think about that when you choose your next probiotic. A yogurt has 1 million bacteria you would have to eat 100,000 million yogurts to equal the amount of bacteria in the appendix.
Methylcellulose is derived from plants and particularly plants high in fiber. Humans do not ruminate their food like cattle. The methylcellulose therefore emerges from the anus altered in physical form but not in chemical formulation. Cattle breakdown with catalase the methylcellulose and the stool that cattle produces is soft like a cow pie.
Bacteria is critical to the formation of stool. When a baby is born the body is sterile both on the inside and out. With time the bacteria from the mother, father, brother, sister and every being in the babies life even the pet dog begin to grow on the skin and in the colon. The baby requires two years of colonization to achieve the level of bacteria in the colon to make a solid stool. The combination of both the methylcellulose and the bacteria therefore produce a normal stool. The normal stool does not disturb the makeup of the anus. The normal stool is the size and consistency of a yellow banana. A brown banana is too soft and a green banana is too hard. The importance of the consistency is most easily seen when the stool comes through the anus. The anus is a self-cleaning mechanism if the stool is well formed as there is no residual stool that is left to wipe off of the anus. If the stool is too soft the skin of the anus, called the anoderm, can become traumatized. The stool contains acid. The acid is used to digest protein which is eaten. This acid, if left on the skin, will burn a hole in the skin. If the stool comes through and leaves no residual then the anoderm is protected.
Another protective measure of the anoderm is oil. The anal skin produces a great deal of oil in the area. The sebaceous glands within the hair follicles are dense in this area and the oil coats the skin. This oil allows for easy of cleaning of the skin of the anus. It also allows for moisture in the area not to emacerate the skin. Think about an area of the body that has no sebaceous glands such as the hands. When the hands are soaked for several hours in water the skin becomes “pickled”. If one washes the anus too much with soap the soap breaks down the oil of the anoderm and then the anus can become “pickled”. This most often is seen with complaints of bleeding, burning and itching of the anus. If one stops the soap the oil will again coat and protect the anus.
Hemorrhoids, if they are chronically swollen emerge from the anus and create hills and valleys where soft stool can collect. This then causes localized irritation in the valleys and results in many patients complaining of hemorrhoids. Yes removal of the hemorrhoids can fix this problem. But an easier solution is to fix the stool. If the stool is well formed it will not get stuck in the valleys or folds of the tissue of the anus. When the anus is swollen from moisture as in the “pickling” mentioned above this again is another etiology that will bring patients in complaining of hemorrhoids. The treatment: stop the soap and improve the formation of the stool.
Did you know...
- Hemorrhoids are one of the most common ailments known.
- More than half the population will develop hemorrhoids, usually after age 30.
- Millions of Americans currently suffer from hemorrhoids.
- The average person suffers in silence for a long period before seeking medical care.
- Today's treatment methods make some types of hemorrhoid removal much less painful.
What are hemorrhoids?
Often described as "varicose veins of the anus and rectum", hemorrhoids are enlarged, bulging blood vessels in and about the anus and lower rectum.
There are two types of External (outside) hemorrhoids that develop near the anus and are covered by very sensitive skin. These are usually painless. However, if a blood clot (thrombosis) develops in an external hemorrhoid, it becomes a painful, hard lump. The external hemorrhoid may bleed if it ruptures.
Internal (inside) hemorrhoids develop within the anus beneath the lining. Painless bleeding and protrusion during bowel movements are the most common symptom. However, an internal hemorrhoid can cause severe pain if it is completely "prolapsed" - protrudes from the anal opening and cannot be pushed back inside.
What causes hemorrhoids?
An exact cause is unknown; however, the upright posture of humans alone forces a great deal of pressure on the rectal veins, which sometimes causes them to bulge. Other contributing factors include:
• Chronic constipation or diarrhea
• Straining during bowel movements
• Faulty bowel function due to overuse of laxatives or enemas
• Spending long periods of time (e.g., reading) on the toilet
Whatever the cause, the tissues supporting the vessels stretch. As a result, the vessels dilate; their walls become thin and bleed. If the stretching and pressure continue, the weakened vessels protrude.
What are the symptoms?
If you notice any of the following, you could have hemorrhoids:
• Bleeding during bowel movements
• Protrusion during bowel movements
• Itching in the anal area
• Sensitive lump(s)
How are hemorrhoids treated?
Mild symptoms can be relieved frequently by increasing the amount of fiber to 30 grams per day (e.g., fruits, vegetables, breads and cereals) and fluids in the diet. Eliminating excessive straining reduces the pressure on hemorrhoids and helps prevent them from protruding. A sitz bath - sitting in plain warm water for about 10 minutes - can also provide some relief .
With these measures, the pain and swelling of most symptomatic hemorrhoids will decrease in two to seven days, and the firm lump should recede within four to six weeks. In cases of severe or persistent pain from a thrombosed hemorrhoid, your physician may elect to remove the hemorrhoid containing the clot with a small incision. Severe hemorrhoids may require special treatment, much of which can be performed on an outpatient basis.
Performed under local anesthesia as an outpatient, this procedure generally provides relief. The patient is given enough intravenous (IV) sedation so that they are comfortably asleep and feel no pain. The patient is treated lying on their back, so that breathing is unassisted and is easy and safe and does not require general intubation anesthesia.
• Ligation – the rubber band treatment - works effectively on internal hemorrhoids that protrude with bowel movements. A small rubber band is placed over the hemorrhoid, cutting off its blood supply. The hemorrhoid and the band fall off in a few days and the wound usually heals in a week or two. This procedure sometimes produces mild discomfort and bleeding and may need to be repeated for a full effect.
• Injection and Coagulation can also be used on bleeding hemorrhoids that do not protrude. Both methods are relatively painless and cause the hemorrhoid to shrivel up.
• Hemorrhoid stapling – this is a technique that uses a special device to internally staple and excise internal hemorrhoidal tissue. The stapling method may lead to shrinkage of but does not remove external hemorrhoids. This procedure is generally more painful than rubber band ligation and less painful than hemorroidectomy.
• Hemorrhoidectomy – surgery to remove the hemorrhoids - is the most complete method for removal of internal and external hemorrhoids. It is necessary when (1) clots repeatedly form in external hemorrhoids; (2) ligation fails to treat internal hemorrhoids; (3) the protruding hemorrhoid cannot be reduced; or (4) there is persistent bleeding. A hemorrhoidectomy removes excessive tissue that causes the bleeding and protrusion. It is done under anesthesia using either sutures or staplers, and may, depending upon circumstances, require hospitalization and a period of inactivity.
Do hemorrhoids lead to cancer?
There is no relationship between hemorrhoids and cancer. However, the symptoms of hemorrhoids, particularly bleeding, are similar to those of colorectal cancer and other diseases of the digestive system. Therefore, it is important that all symptoms are investigated by a physician specially trained in treating diseases of the colon and rectum and that everyone 50 years or older undergo screening tests for colorectal cancer. Do not rely on over-the-counter medications or other self-treatments. See a colorectal surgeon first so your symptoms can be properly evaluated and effective treatment prescribed.