HAEMORRHOIDS

Background

Haemorrhoids (or piles) are swellings of the blood vessels within the anal canal. Everyone has these blood vessels and it is only when they become bigger and cause problems that we refer to them as haemorrhoids. This is commonly in response to constipation and straining. Haemorrhoids can be defined as either internal (inside the anal canal) or external (outside the anal canal). To confuse the matter internal haemorrhoids can prolapse out of the anus and appear external.

Haemorrhoids can be graded as follows:

Grade 1 : Internal haemorrhoids that bleed but cannot be seen outside the anus
Grade 2 : Internal haemorrhoids that prolapse down and reduce spontaneously
Grade 3 : Internal haemorrhoids that prolapse down and need to be manually reduced (pushed back up)
Grade 4 : Internal haemorrhoids that are permanently prolapsed and can not be reduced.

Haemorrhoids can cause a variety of symptoms. The most common is bleeding, which is typically a bright red blood (like if you cut your finger) after a bowel action. This may be noticed on the toilet paper or in the toilet bowl (NB. A little bit of blood always looks like a lot in the toilet bowl water!). Some may notice a lump around their anus and may need to push it back in after a bowel action. Very large haemorrhoids can sometimes cause problems with mucous leakage. Anal pain is often attributed to haemorrhoids however this is by far a less common symptom from haemorrhoids. Usually only haemorrhoids that have prolapsed down and have become thrombosed (a blood clot within them) will cause pain. It is less common for internal haemorrhoids to cause pain and often this is from another cause.

Management

Conservative

The first step in haemorrhoid management is to avoid constipation. Steps to avoid constipation include adequate water intake and a high fibre diet. You may even require laxatives if your constipation is particularly bad. Fibre supplements such as Metamucil have been proven to reduce the bleeding from haemorrhoids. For many people, symptoms from haemorrhoids are only transient lasting a few days to a couple of weeks. You may require a colonoscopy to investigate and exclude other causes of bleeding.

Thrombosed haemorrhoids

Thrombosed haemorrhoids are very common. This is where a clot develops within a haemorrhoid on the outside of the anus. It is typically about the size of a grape and purple in colour. The vast majority of these will settle on their own within days to weeks. Occasionally they may ulcerate over the top and bleed. Some doctors may incise (lance) the haemorrhoid to evacuate the clot. This will usually only provide temporary relief and the pain and bleeding will return. Ultimately time is the best medicine for a thrombosed haemorrhoid. Surgery can be performed but will often only replace the pain from the haemorrhoid with at times worse pain from the surgery. Steps which can be taken to help in the meantime include pain killers, ice packs, laxatives and the various topical creams available over the counter (eg Rectinol, Proctosedyl, Scheriproct).

Operative

For some people, the symptoms of haemorrhoids do not settle down and surgery may be an option. The choice of procedure will be discussed with you during your consultation. This will depend on your symptoms as well as the size and grade of your haemorrhoids. It may also depend on what procedures you have had performed previously.

Rubber band ligation and sclerotherapy
For Grade 1 and Grade 2 haemorrhoids as well as some smaller Grade 3 haemorrhoids you may be suitable to undergo rubber band ligation or sclerotherapy (injection of a liquid to create scarring). This can be performed as a day procedure under either light sedation or a general anaesthetic. Rubber band ligation involves inserting multiple (often 3 or more) small rubber bands just above the top of the haemorrhoids. This cuts off the blood supply to the haemorrhoids and reduces congestion. This is a relatively painless procedure though some may experience some discomfort in the first few days. You may experience some intermittent bleeding in the first couple of weeks after the procedure, however this will usually settle on it's own. On rare occasions the bleeding may be large enough that you require further procedures to treat it. You may also get the urge to open your bowels even when they are empty, this is called tenesmus. This procedure has a success rate of about 70-80% when performed on the appropriate haemorrhoids. Rubber band ligation can often be performed in conjunction with either a colonoscopy or flexible sigmoidoscopy.

Haemorrhoid artery ligation and rectoanal repair (HAL-RAR) or Transanal haemorrhoidal dearterialisation (THD)
This is a relatively new procedure and is typically used for grade 2 and 3 haemorrhoids and is particularly good for circumferential haemorrhoids. It involves the use of a Doppler probe to locate the vessels feeding the haemorrhoids higher up within the anal canal. A suture is then tied around these vessels to cut off the blood supply. A second suture is then placed, called a mucopexy stitch, to lift the haemorrhoid back within the anal canal and prevent prolapse.

The benefit of this procedure is there is no cutting involve which generally equates to less pain. However some small skin tags may be cut out at the same time. In our experience this procedure is not as good when dealing with very large grade 4 haemorrhoids. Recent evidence does suggest that whilst short term results are good, the long term recurrence rate may be as high as 20%. This rate will go up the worse the haemorrhoids to start with. Complications from this procedure are uncommon but include bleeding, infection and urinary retention. As there is no cutting involve the risk of continence problems is rare.

This can be performed as a day case, but more commonly an overnight stay in hospital. This is not a completely painless procedure, with most experiencing some pain particularly with bowel actions over the first few days.

Haemorrhoidectomy
This is the traditional operation for haemorrhoids and has stood the test of time. This involves cutting out the haemorrhoids. It does have the highest success rate in "curing" your haemorrhoids but does come at price, namely pain. Most will experience pain, which is usually with bowel actions and lasting for several hours after for a couple of weeks. This is usually manageable with just tablet pain relief. The wounds will either be left open or partially closed with dissolving sutures. Other potential complications from a haemorrhoidectomy include bleeding, excessive scar tissue creating an anal stenosis, a persistent non-healing wound called a fissure, and damage to the underlying sphincter muscles. These complications however are relatively rare.