Hemorrhoids, which are popularly known as piles, are an amazingly common anorectal conditions and yet seldomly discussed. Pathologically, Hemorrhoids are the abnormal distal displacement of the anal cushions that results in dilatation of anal veins.
It is characterized by the symptomatic enlargement and downward displacement of the normal anal support and protective systems. This medical condition is a serious condition as it is believed to affect a lot of people all over the globe and constitutes a major part of medical and socioeconomic problems.
For instance in USA, about 50% of Americans have pile by the age of 50 years but just 500,000 of these individuals look for medical assistance for the issue. Out of these 500,000 individuals, between 10% and 20% require medical procedure to have their hemorrhoids expelled.
Causes of Hemorrhoids
Multiple factors have been linked to be the cause of hemorrhoids, these include:
- Constipation and prolonged straining.
- Abnormal dilatation and distortion of the vascular channel,
- Destructive changes in the supporting connective tissue within the anal cushion
- An inflammatory reaction
- Vascular hyperplasia
Pathophysiology of Hemorrhoid
The truth is, the exact pathophysiological processes associated with the development of hemorrhoid is not fully understood. Although we have been made to believe that hemorrhoids were caused by varicose veins in the anus, but that is not so now.
Of recent, the theory that postulates sliding anal canal lining is what is generally accepted, “it proposes that hemorrhoids develop when the supporting tissues of the anal cushions disintegrate or deteriorate”.
Anal cushions are specialized submucosal tissues that lined the anal canal which helps to control stool passage. It is categorized into major and minor cushions. The major anal cushions are basically three based on where they are located namely the right anterior, right posterior and left lateral while the minor cushions are found lying between these major cushions.
People with hemorrhoids usually have disordered anal cushions due to abnormal venous dilatation, vascular thrombosis, collagen fibers and fibroelastic tissues degeneration, distortion and rupture of their anal subepithelial muscle.
Epidemiology of Hemorrhoids
The true epidemiology of pile is not known because most patients with hemorrhoids usually self-medicate instead of seek medical attention from a practitioner.
Although a study by Johanson et al in 1990 which was conducted in USA revealed that 10 million people suffer from hemorrhoids. This shows that the prevalence rate of hemorrhoids is as high as 4.0%. This prevalence rate was observed to peak between the age range of 45-65 years in both male and females.
It further revealed that people less than 20 years rarely develop hemorrhoids but if it does occur then it is very unusual. Although all races are affected, but Caucasians and higher socioeconomic status individuals were found to be more affected than Negros and lower socioeconomic status individuals.
Risk Factors of Hemorrhoids
Constipation and prolonged straining is one of the major risk factors of hemorrhoids, it causes your stool to be hard and increases intraabdominal pressure. This effect results in obstruction of venous return, which leads to swelling of the vessels in the anal canal.
Another risk factor for the development of hemorrhoids is diarrhea. During episodes of diarrhea, there is usually an Increase in straining which may unexpectedly cause hemorrhoidal symptoms such as bleeding to develop.
Pregnancy is also a risk factor for hemorrhoids, which can cause congestion of the anal cushion and symptomatic hemorrhoids. They are often resolved after delivery.
Others include dietary factors such as low fiber diet, spicy foods and alcohol intake.
Classification and Grading of Hemorrhoids
On the basis of their location, Hemorrhoids are classified into three namely:
- Internal hemorrhoids: This type of pile arises from the inferior hemorrhoidal venous plexus located above the dentate line and is protected by mucosa.
- External hemorrhoids: This type of hemorrhoid occurs when the venules plexus are dilated and they are located below the dentate line covered with squamous epithelium.
- Mixed (interno-external) hemorrhoids: This originates from both above and below the dentate line.
Further studies suggest classification of Internal hemorrhoids based on their appearance and degree of prolapse into grades namely:
- Grade I (First-degree hemorrhoids): There is bleeding of the anal cushions without prolapse;
- Grade II (Second-degree hemorrhoids): There is prolapse of the anal cushions through the anus on straining however the prolapse reduces without external efforts.
- Grade III (Third-degree hemorrhoids): Here the anal cushions prolapse through the anus on straining or exertion but it is put back into the anal canal using the hands.
- Grade IV (Fourth-degree hemorrhoids): The anal cushions prolapse and remain outside at all times. It does not reduce as in grade II. Common examples of Grade IV hemorrhoids are acutely thrombosed, incarcerated internal hemorrhoids and incarcerated, thrombosed hemorrhoids involving circumferential rectal mucosal prolapse.
Signs and Symptoms of Hemorrhoids
The following are the main signs and symptoms of hemorrhoids:
- Painless rectal bleeding associated with bowel movement
- Anal itching
- A feeling of incomplete rectal emptying or rectal fullness
- Anal Pain due to fissure or perianal abscess
Treatment of Hemorrhoidal Disease
Treatment of Hemorrhoids depends largely on the degree and severity of the symptoms. It includes:
- Non-pharmacological approach
- Pharmacological approach
- Non-Surgical approach
- Surgical approach
This includes dietary and lifestyle modifications. Like earlier stated that people with pile pass hard stool while defecating this may lead to shearing of the anal mucosa which damages the anal cushions and cause symptomatic hemorrhoids.
To eliminate straining during stooling take foods that contain a lot of fibers such as whole grains, wheats, barley, berry, oats, peas, carrots, melons, oranges, pineapple, nuts and seeds e.t.c. Intake of these foods with fiber will reduce your risk of persistent symptoms and rectal bleeding by 50% but does not improve your symptoms of pain, itching and prolapse, so use fibrous foods or supplements when you want to treat non-prolapsing hemorrhoids.
Although the use of fibres in hemorrhoids may take upto 6 weeks for pronounced improvements to be seen, so it requires patience and consistency.
This is one of the cheapest and safest approaches to initial treatment of hemorrhoids and forms an integral part of your therapeutic course.
Lifestyle changes also play a role in the treatment and prevention of hemorrhoids, they are as follows:
- Increase dietary fiber intake and oral fluids,
- Lower fat consumption,
- Engage in routine exercise,
- Improve anal hygiene,
- Restrain from straining and reading on the toilet when defecating, and
- Avoid drug that causes constipation or diarrhea.
Oral calcium dobesilate: It is a venotonic agent that is mostly used in people with diabetic retinopathy. It is also used in the treatment of chronic venous insufficiency and acute symptoms of hemorrhoids. Clinical studies showed that calcium dobesilate when used together with foods or supplements containing fiber improved the symptoms of acute bleeding and hemorrhoidal inflammations.
Oral flavonoids: These are also called venotonic agents because they act mainly on the veins to treat chronic venous insufficiency and edema. Although their mechanism of action is not fully understood however they seems to increase vascular tone, reduce venous capacity, decrease capillary permeability, and facilitate lymphatic drainage as well as exert anti-inflammatory activities. Studies revealed that flavonoids reduce the risk of bleeding, persistent pain, itching and the rate at which hemorrhoids recurs.
Topical treatment: The idea behind using topical medications in the management of hemorrhoids is to provide relief from symptoms rather than treat the medical condition. They contain ingredients such as corticosteroids, antibiotics, local anesthesia, and anti-inflammatory drugs.
Sclerotherapy: Of recent sclerotherapy has been claimed to be effective in the treatment of first- and second-degree hemorrhoids. It is usually injected into submucosal layer of the hemorrhoid tissue, this is done to fix the mucosa to the underlying muscle by fibrosis.
Rubber band ligation: This is use for the treatment of first- and second-degree hemorrhoids and selected patients with third-degree hemorrhoids.
Infrared coagulation: This procedure utilizes a machine called infrared coagulator. This medical instrument creates infrared radiation which coagulates tissue and evaporizes water in the cell, causing shrinkage of the hemorrhoid mass.
Others include Radiofrequency ablation, Cryotherapy.
Surgical procedures are conducted only when the above non-operative or non-surgical procedures failed or when complications develop. These surgical measures include:
Excisional Hemorrhoidectomy: This is a very effective treatment of hemorrhoids with the lowest rate of recurrence. It is used when non-operative management failed, when there is thrombosis, or when patient prefers it to other modalities, and/or when there is associated anal fissure or fistula-in-ano which require surgery. One of the major draw backs of Hemorrhoidectomy is pain after the operation.
Plication: This method can restore anal cushions to their normal position. There are complications that occur after plication such as rectal bleeding and pelvic pain.
Others include: Doppler-guided hemorrhoidal artery ligation, Stapled hemorrhoidopexy:
Prevention of Hemorrhoids
Lifestyle changes and good diet regimens play vital roles in the prevention of hemorrhoids. To avoid getting hemorrhoids do the following:
- Take more foods containing fiber,
- Increase oral fluids intake,
- Reduce the consumption of fatty foods e.g pork, butter, coconut oil, cheese, chocolate
- Begin regular exercises,
- Improve hygiene and sanitation, particularly anal hygiene and toilet.
- Do not strain as it can increase pressure on your venous cushions. When you visit the toilet immediately you feel the urge to defecate you will avoid straining. You strain when your stool becomes hard.
- Avoid reading on the toilet bowl when defecating,
- Avoid taking drugs that may cause constipation or diarrhea, always seek for medical advice.
1. Aigner F, Gruber H, Conrad F, Eder J, Wedel T, Zelger B, Engelhardt V, Lametschwandtner A, Wienert V, Böhler U, et al. Revised morphology and hemodynamics of the anorectal vascular plexus: impact on the course of hemorrhoidal disease. Int J Colorectal Dis. 2009;24:105–113. [PubMed] [Google Scholar]