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Hemorrhoids

What are hemorrhoids?

Hemorrhoids are cushions of highly vascular tissue that are located at the anal canal of all healthy individuals.(1,2)

They are composed of:

  • Connective tissue

  • Smooth muscle

  • Blood vessels

  • Elastic tissue

One of their role is to help maintaining anal continence.

Although hemorrhoids are normal structures, the term “hemorrhoids” has come to refer to pathologic condition more scientifically called hemorrhoidal disease or sometimes hemorrhoidal crisis.

What is hemorrhoidal Disease?(3,4)

The mechanism of hemorrhoidal disease development is still poorly understood.

While in the past pathologic hemorrhoids were thought to be anorectal varices, the actual hypothesis of their origin is local tissular deterioration.

What are the manifestations of hemorrhoidal disease? (3,4)
  • External hemorrhoids can thrombose (formation of a blood clot in hemorrhoidal vessels) and induce:

    • Acute and throbbing pain (Most common symptom).
    • Sensation of a painful perianal mass.
    • Dark and clotted bleeding.
  • Internal hemorrhoids can prolapse and/or thrombose, inducing:

    • Red bleeding (most common symptom, it usually happens during defecation and it is almost always painless. Blood coats the stools and is found on toilet paper and/or into the bowl).
    • Moderate fecal incontinence.
    • Irritation of perianal skin (Itching or burning).
    • Mucus discharge.
    • Pain (more rarely).
    • Sensation of tissue prolapse or perianal fullness.
  • Under normal circumstances

    • Hemorrhoidal disease is generally painless with only local discomfort feeling.
    • An hemorrhoidal crisis refers to an exacerbation of symptoms (i.g. an acute and throbbing pain that occurs in conjunction with thrombosis).

What are the risk factors of hemorrhoidal disease? (3,4,5,6,7)

Identified risk factors of hemorrhoidal disease include

  • Overweight

  • Prolonged defecating position/
    sitting position

  • Situations in which abdominal pressure is increased

  • Insufficient dietary fibers intake

  • Heavy lifting

  • Transit dysregulation -
    constipation, chronic diarrhea

  • Family history

  • Pregnancy

  • Ageing

  • Local impairment - Anal intercourse, rectal pathology

  • Straining for defecation

  • Insufficient oral fluids intake

  • Alcohol, fatty or spicy food

As prolonged physical inactivity can promote constipation, it might also be considered as a risk factor of hemorrhoidal disease.

Diagnosis

Exact data on hemorrhoidal disease prevalence are rare. The true prevalence is inevitably underestimated due to the under-reporting of these symptoms. It is estimated to be up to 40% of the general population.

Are "hemorrhoids" frequent? (8,9,10)

Hemorrhoids are very common during pregnancy and post-partum.

Up to 85% of pregnant women

This can be explained by the physiological changes occurring during pregnancy as well as the frequent occurrence of constipation.

How should I know if I have hemorrhoidal disease? (1,3)

All symptoms of hemorrhoids are non-specific. Many other conditions may be concomitantly present or cause similar symptoms (anal fissure, malignancy, inflammatory bowel diseases...).

Therefore, a thorough medical examination is necessary for diagnosis. It includes:

  • External inspection;
  • Digital examination;
  • Further examinations.

If you experience blood in the stool, it is recommended to see a doctor as soon as possible as this sign may be caused not only by hemorrhoids but also by more severe pathologies.

What are the treatment methods for hemorroidal disease?
What are the treatment methods for hemorrhoidal disease? (8,11,12,13)

External hemorrhoids

Usually require no specific treatment unless they become acutely thrombosed or causes patients discomfort.

Internal hemorrhoids

Can be effectively treated with lifestyle and dietary measures, medication, instrumental measures and/or surgery.

Lifestyle and dietary measures

The objective is to prevent or reduce pathological development or symptoms of hemorrhoidal disease.

It includes:

  • Increasing dietary fibers and oral fluids intake consumption;
  • Avoiding straining and prolonged defecation position;
  • Avoiding anal intercourse;
  • Performing regular exercise.

  

Before starting any treatment, it is essential to consult your doctor or pharmacist for advice.
INSTRUMENTAL AND SURGICAL TREATMENT

The objective is to induce fibrotic scarring of internal hemorrhoids.

  • Rubber band ligation: Hemorrhoids are tied off with rubber bands leading to their obliteration.
  • Infrared coagulation: The infrared light converted into heat allows coagulation of hemorrhoids.
  • Sclerotherapy: Sclerosant drugs are injected at the base of the hemorrhoid leading to an inflammatory response and shrinking of hemorrhoids.
  • Surgery is generally restricted to the most severe forms of hemorrhoids. A wide range of technic are available.
PHARMACOLOGICAL TREATMENT

The objective is to relieve symptoms.

  • Modifiers of intestinal transit can help regulate the consistency or frequency of stools.
  • Phlebotonics are drugs that reduce capillary fragility and improve microcirculation in venous insufficiency. They are effective for overall symptom improvement of hemorrhoidal disease. They are recommended for short-term use in cases of acute manifestations of hemorrhoids (hemorrhoidal crisis), in particular bleeding and pain. Phlebotonics can usually be used during pregnancy lactation and post- partum.
  • Non-steroidal anti-inflammatory drugs (NSAIDS), analgesics, and cortisone derivatives can be used in case of pain caused by thrombosed hemorrhoids. However they should be used carefully for safety reasons.
  • Localized topical treatments (suppositories, creams or ointments) combining, to varying degrees, applied corticosteroids, anesthetics, lubricants, protectors and phlebotonics can also be indicated.
  • For pregnant women, only certain medications can be used, with caution. Hip baths can help reduce hemorrhoidal pain. 

Disease management: the word of expert

References:

1. Sneider E.B, et al. Diagnosis and Management of Symptomatic Hemorrhoids. Surg Clin N Am 90 (2010) 17–32. 
2. Sandler R.S, et al. Rethinking what we know about hemorrhoids. Clinical Gastroenterology and Hepatology 2019;17:8–15. 
3. Sun. Z et al. Review of Hemorrhoid Disease: Presentation and Management. Clin Colon Rectal Surg (2016). 29, 22–29. 
4. Geçim E., et al. Haemorrhoidal Disease Management. EMJ Gastroenterol. 2017; 6[Suppl 6]:2-12. 
5. Margetis N. Pathophysiology of internal hemorrhoids. Annals of Gastroenterology (2019)32, 1-9. 
6. Lohsiriwat V. Hemorrhoids: From basic pathophysiology to clinical management. World J Gastroenterol 2012 May 7; 18(17): 2009-2017. 
7. Iovino P et al. New onset of constipation during long-term physical inactivity: a proof-of-concept study on the immobility-induced bowel changes. PLoS One. 2013 Aug 20;8(8):e72608. 
8. Perera N, et al. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev (2012). CD004322. 
9. Riss S, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis (2012) 27:215-220. 
10. Vazquez J.C. Constipation, haemorrhoids, and heartburn in pregnancy. BMJ Clin Evid 2008. 
11. Ohsiriwat V. Treatment of hemorrhoids: A coloproctologist’s view. World J Gastroenterol. 2015 Aug 21;21(31): 9245–9252. 
12. Higuero T, et al. Guidelines for the treatment of hemorrhoids (short report). J Visc Surg (2016). 153, 213–218. 
13. Abramowitz L. Management of hemorrhoid disease in the pregnant woman. Clinic and Biologic Gastroenterology (2008) 32, S210-S214.