People usually panic when they see blood coming out from them even if they are not in pain.

Today we are discussing one of the most common causes of painless bleeding from the anus and lower rectum. Today we are discussing hemorrhoids, or also known as piles.

So, what are Hemorrhoids? How do we get them?

In one sense, all of us have hemorrhoids, the pillow-like clusters of veins that lie just beneath the mucous membrane that lines the lowest part of the rectum and the anus. But we call them hemorrhoids or piles when they become swollen and engorged like varicose veins. There are two types of hemorrhoids; internal hemorrhoids when they develop inside the rectum, and external hemorrhoids when they develop just under the skin around the anus. External hemorrhoids are the most annoying type because the overlying skin gets irritated and might ulcerate.

Some people think varicose veins and hemorrhoids are the prices we pay for being upright creatures because our blood has to fight against gravity to go back to the heart. Although hemorrhoids have several causes, the cause is often unknown.

Some doctors correlate hemorrhoids to increased pressure as in pregnancy when the enlarged uterus presses on the pelvic veins, overweight and obesity, chronic constipation, straining during defecation, or prolonged sitting on the toilet. All of which interfere with the blood flow to and from this area.

But as we said, often the cause is unknown because, for instance, not all pregnant women get piles and not all overweight people get them either. On the contrary, you might find a thin person suffering from piles. More recent studies show that people who get hemorrhoids have higher resting anal canal tone. The smooth muscle of the anal canal is tighter than the rest of the canal even when not straining. So, constipation adds to this pressure and these veins tend to stretch under pressure, so they start pushing against this small muscle, and eventually, the tissue that supports and holds hemorrhoids in place weakens and the veins bulge or prolapse. In fact, nearly three out of four adults will have hemorrhoids from time to time. So, millions of people around the world have hemorrhoids. It represents a major medical and socioeconomic problem.

But how do they know they have piles? What are the symptoms?

Symptoms vary according to the type of hemorrhoids.

In external hemorrhoids, for instance, patients complain of:

Pain or discomfort.
Itching and irritation on the skin around the anus.
Bleeding.
Swelling around the anus.

On the other hand, internal hemorrhoids which lie inside the rectum, can't be seen or felt. They are typically painless and rarely cause discomfort even when they bleed. However, straining during defecation might cause:

Bright red blood dripping from you on the toilet paper or in the toilet bowl.
Prolapsed or protruded hemorrhoids coming out of the anal opening causing irritation and pain.

Protruded hemorrhoids collect small amounts of mucus and stools which in turn causes itching and irritation called “Pruritus ani”.

Complications can be really annoying. If blood pools in the external hemorrhoids, a blood clot forms inside one of them. It can result in sudden severe pain, swelling, inflammation, and a hard lump near the anus. When the clot dissolves, it leaves excess skin that might be itchy or irritating. Although it is not dangerous, it is extremely painful and sometimes needs to be drained.

Another significant complication is anemia. Chronic blood loss may cause anemia.

If the blood supply coming to one of the internal hemorrhoids is cut off, it will be strangulated and will cause severe pain.

Risk factors of hemorrhoids are related to age somehow. As we age, the risk for hemorrhoids increases. That’s mainly because the tissues that support the veins in their place weaken over time and stretch. This way it gives the veins space to expand and bulge.

As for the diagnosis of hemorrhoids or piles, simple medical history and physical examination will lead to the right diagnosis. Your doctor will be able to see the external hemorrhoids apparent around the auns easily especially if there a clot has formed.

Diagnosing the internal hemorrhoids, however, might include another type of examination. Your doctor will probably perform a digital rectal examination where he/she inserts a gloved lubricated finger into the anus and lower rectum to check for blood in the stool. Your doctor may also use an anoscope; a short plastic tube provided with illumination inserted in the anal canal for examination.

The case might also require the use of flexible sigmoidoscopy or colonoscopy to rule out other causes of bleeding such as polyps and cancers especially if the patient is above 45 years old.

If your doctor suspects another digestive tract disease, the risk for colorectal cancer, or you are a middle-aged patient who hasn’t had a colonoscopy recently, he or she will examine the whole colon using colonoscopy.

Now, it is time to discuss the treatment of piles or Hemorrhoids

You might think it is a complicated condition that needs surgeries to be corrected. Contrary to this popular belief, hemorrhoids can be significantly improved using home remedies. You can relieve mild pain, swelling and inflammation with home treatments.

Here are some of the most effective home remedies for hemorrhoids:

High-fiber foods. Eating a lot of fruits, vegetables and whole grains is the cornerstone to soften stools and increase their bulk and, consequently, avoid straining that can worsen symptoms for your existing piles.
Soaking regularly in a warm bath or sitz bath. Soaking your anal area in a plain warm bath for 10 to 15 minutes two or three times a day will help you reduce inflammation and treat piles.
Using topical treatments. There are some over-the-counter hemorrhoids treatments used on the anal area as creams or suppositories. They contain hydrocortisone or numbing agents. Also, there are pads used for piles.
Oral pain killers. Using ibuprofen, paracetamol or aspirin will help you decrease the discomfort.

This treatment will help you get rid of the symptoms in a week. But always consult your doctor before using over-the-counter remedies for more than a week because they might thin your skin.

But what if the symptoms don’t go away? Or what if you had Thrombosed piles already?

If a clot has formed in your hemorrhoids, your doctor will offer to drain them and get the clot out. It is better to be done within 72 hours after developing the clot. It is done under local anesthesia and provides instant relief.

As for resistant pain or persistent bleeding, there are some minimally invasive procedures that your doctor might offer. They can be done in your doctor’s office or the outpatient clinic with no need for anesthesia.

They include:

Rubber band ligation. Your doctor will put a small rubber band around the base of the internal hemorrhoidal veins to cut the blood supply off them to induce their shrinkage within a week.
Injection sclerotherapy. Injection of a chemical solution into the hemorrhoids to induce their shrinkage or falling off. The injection might cause little or no pain. It is less effective than rubber band ligation.
Coagulation. Using laser or infrared light or heat to cause small bleeding in internal hemorrhoids so they harden and shrink. This technique causes discomfort for the patient.

Only a small percentage of people will require a surgical procedure to remove hemorrhoids when they can’t be managed by conservative treatment or when symptoms persist after all the previous solutions or when hemorrhoids are large and protruding.

The most common procedure is hemorrhoidectomy which means removal of hemorrhoids. It can be done under local anesthesia combined with sedation, spinal anesthesia, or general anesthesia. Your doctor will remove the excess tissue that is causing the persistent bleeding. Complications include urine retention which might lead to urinary tract infection.

However, it is, hands down, the most effective and complete way to treat severe or recurring hemorrhoids.

There is also stapling in which blood flow to the hemorrhoids is blocked. It is only an available solution for internal hemorrhoids. It is less painful than a hemorrhoidectomy, however, it is correlated with a higher risk of recurrence or rectal prolapse in which the rectum protrudes from the anus. Complications also include urine retention and bleeding.

Our role today is to answer most of your questions regarding hemorrhoids. Today we have Dr. Ahn, who is a leading doctor at Hanyang University Hospital in Seoul. He is going to discuss with us about hemorrhoids from an experienced medical point of view.

Interview

What is hemorrhoids?

Hemorrhoids is the presence of protrusions of swollen veins outside of the anus. The chances increase with age and gender being female.

Any symptoms that we should watch out?

The most common symptom of hemorrhoid is rectal bleeding during bowel movements. Another is the protrusion of tissue outside the rectum. At times, the protrusion goes back in and at times they stay outside, which can often be put back inside by finger push. Other than those, we can say pain is a symptom.

It’s really important to have examinations, right?

When you have these types of symptoms and visit a hospital, a visual exam and checkup of the rectum with finger is vital, as well as endoscopy.

In the case that it is confirmed it’s hemorrhoids, what kind of treatment are there?

We can divide the treatments into surgical and non-surgical. And depending on the severity, we can decide whether to take the surgical route or non-surgical route for treatment. There are four stages of hemorrhoids, from first to fourth. In the first stage, there is no protrusion but there is bleeding. Also, you can feel a lump if a finger is inserted. In the second stage, there is protrusion, but it tends to go back inside on its own in due time. In the third stage, the protrusion tends to not go back inside on its own, so it needs the assistance of a finger push. In the fourth stage, even if pushed back, the protrusion does not return inside. So, in general we recommend surgery for stages three and four, where a finger assistance is needed to place back the protrusion. But even in second stage, we sometimes recommend surgery if the patients tends to lose lots of blood leading to anemia.

I didn’t know there are so many levels.

In the case of third stage and up, is there any diet that you should follow after the surgery?

Hemorrhoids tend to worsen if there is constipation or frequent bowel movements during diarrhea, it is best to avoid foods that promote constipation or diarrhea. If one has constipation, the patient should eat foods or intake medicine that soften stool, or if one has diarrhea, medicine should be taken to reduce it in order to make the stool more solid. Also, alcohol and tobacco, especially alcohol should be avoided.

Last question…what should we do to prevent hemorrhoids from the beginning?

Avoid spending long times sitting on the toilet, and since constipation and diarrhea worsens hemorrhoids, it is best to avoid such circumstances. Also, when too much alcohol is consumed, the hemorrhoids worsen due to dilation of veins. Those who consume lots of alcohol tend to have a very dire time, so it is best to avoid drinking. Also, it is best to avoid stressful situations. And for pregnant women, special care is needed as they tend to be prone to hemorrhoids as those who have hemorrhoids tend to worsen and those who never had hemorrhoids are at increased risk during pregnancy.

Conclusion

According to Dr. Ahn’s interview, hemorrhoids tend to occur in people as they age and more particularly, women. The most common symptom is bleeding during bowel movements. Also, there could be something protruding outside. Sometimes they disappear on their own, and in some cases one can place back the protruding tissue back into the rectum by using one’s fingers. These could be accompanied by pain. These are the most common symptoms.

To ascertain the presence of hemorrhoids, a doctor would do a visual checkup of the rectal area as well as using an endoscope to examine further. Once hemorrhoid presence is conclusive, there are surgical and non-surgical methods to cure the condition.

Whether a surgical cure is deployed, depends largely on the severity and stage of the condition, which can be divided into four distinct phases. Stage one is when there is rectal blood and hemorrhoids can be felt with a finger exam inside the rectum. Stage two is when there is outside protrusion but tends to return into the rectal area on its own. The third is when there is protrusion outside that does not go back inside unless pushed by finger. The fourth stage is when the protrusion does not get back inside even when pushed back. The stages where surgery is typically recommended are hemorrhoids in stages three and four. But, sometimes even in stage two, if the patient bleeds too much leading to anemia, then surgery is also the recommended procedure.

In order to prevent hemorrhoids, it is important to avoid constipation. So, intake lots of foods that produce soft stool, such foods high in dietary fibers and avoid foods that are known to cause constipation. Also, it is good to avoid foods that may cause diarrhea, as it can also cause inflammation of the rectal area and lead to hemorrhoids. Both can be aided by proper foods and supplements. Also, it is best to avoid alcohol and tobacco, but especially alcohol. In summary, avoid spending prolonged periods in the toilet to help prevent this condition.