AETIOLOGY AND RISK FACTORS
VOL: 99, ISSUE: 07, PAGE NO: 28
AETIOLOGY AND RISK FACTORS
- Anal cushions are important structures within the anal canal that help form a seal within the canal when it is at rest. Haemorrhoids, commonly known as piles, occur when the anal cushions are enlarged and swollen, or displaced.
- They can be described as follows:
By location: Internal haemorrhoids occur just above the anal sphincter, while external haemorrhoids are found just under the skin at the lower end of the anal canal;
By area: Left lateral, right posterior or right anterior anal cushion;
Primary (found within anal cushion) or secondary (found between anal cushions).
- In addition, they can be classified into four degrees:
First degree: bleeding but no prolapse;
Second degree: prolapse outside anal canal but retracts spontaneously;
Third degree: prolapse requiring manual replacement into anal canal;
Fourth degree: prolapsed and cannot be manually replaced. Usually strangulated and/or thrombosed.
- Increased pressure from straining to defecate.
- Decreased venous pressure due to pregnancy or obesity.
- Weakening of the support structures due to ageing.
- Prolonged sitting on toilet may interfere with venous return due to tourniquet effect.
SIGNS AND SYMPTOMS
- Fresh bleeding during/after bowel movements.
- Prolapse of external haemorrhoids.
- Itching, pain.
- Mucous discharge.
- Difficulty cleaning after opening bowels due to skin tags caused by external haemorrhoids.
TREATMENT AND THERAPIES
- High-fibre diet and increased intake of fluids.
- Education on toilet habits, for example reduce time on toilet, open bowels only when feel urge to do so.
- Regular warm baths, cold compresses to relieve symptoms.
- Soothing haemorrhoidal preparations.
- Rubber band ligation.
- Stapled haemorrhoidectomy.
- Both surgical and non-surgical patients require health education regarding causes of haemorrhoids, complemented by advice on diet, toilet habits, prevention of constipation and self-management of symptoms.
- For surgical patients, consideration should be given to the type of analgesia supplied, as opiates are likely to increase the risk of postoperative constipation.
- Provision of a stool softener may be appropriate. A high-fibre diet should not be recommended until patient can open the bowels without pain, as there is a risk that they will become impacted. Risks associated with haemorrhoidectomy include temporary urinary retention, anal stenosis, excessive bleeding and a - usually temporary - reduced ability to control flatus.
RESEARCH AND DEVELOPMENT
- Haemorrhoidectomy is performed as a day case in many centres.
- Stapled haemorrhoidectomy - developed in the mid-1990s - is reported to reduce postoperative pain and speed up return to normal activity. Its long-term effect on anal function requires further study.
National Institute of Diabetes and Digestive and Kidney Diseases: www.niddk.nih.gov
American Society of Colon and Rectal Surgeons: www.fascrs.org
NHS Direct: www.nhsdirect.nhs.uk/nhsdoheso/display.asp?sTopic=Haemorrhoids