Sarah Metlova
What Are Hemorrhoids And How To Get Rid Of Them – Below is a comprehensive overview of how to diagnose and stage hemorrhoids, as well as how to choose the appropriate medication or surgical treatment based on current clinical evidence.
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What Are Hemorrhoids And How To Get Rid Of Them
Aspects of modern life that can promote hemorrhoids include eating processed foods, a sedentary lifestyle, and using cell phones during urination, which means spending a lot of time on the toilet.
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Hemorrhoids accounted for more than 3.5 million hospital visits in the US in 2010, and were the third leading cause of gastrointestinal-related hospital admissions.
Here we review the process of diagnosing hemorrhoids as well as choosing the appropriate medication or surgery based on the latest clinical evidence.
Hemorrhoids are a deep discharge of a bunch of veins, muscle fibers and surrounding tissue in the form of an envelope below the tooth line in the anus. They usually present with painless rectal bleeding.
The diagnosis of hemorrhoids is based on history and physical examination rather than laboratory tests or imaging studies. Usually, the first symptom is painless rectal bleeding associated with a bowel movement, usually seen as bright red blood on the toilet paper or stool. Great pain and anxiety are also common, especially with nausea.
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A detailed patient history is important. This includes the extent, severity, and duration of symptoms, frequency of bowel movements, associated symptoms (eg, constipation, loose stools), daily dietary habits, and details about bowel movement (eg , time spent during each bowel movement and mobile phone simultaneously). use) should be included. ,
Regarding bowel movements, some patients experience constipation or diarrhea. Therefore, what a patient perceives as normal bowel habits may be abnormal and should be investigated.
A digital rectal exam is the second step. On examination, look for skin tags, sphincter tone, perianal hygiene, and synovial lesions in the anus.
Red flags for colon cancer on digital exam include a mass with or without the presence of a hemorrhoidal sac and a source of bleeding higher than the level of the internal hemorrhoid.
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Patients with recurrent abscesses, fistulas, or skin lesions (especially cauliflower-like lesions) should be tested for Crohn’s disease (Figure 1).
Because rectal bleeding can be a sign of many diseases, including colon cancer, it is important to review previous endoscopic results. Patients at high risk for colon cancer should undergo rigid proctoscopy, flexible sigmoidoscopy, or colonoscopy.
In our practice, we recommend endoscopic evaluation for patients over 40 years of age with rectal bleeding, especially if they have a family history of colon cancer.
External hemorrhoids are identified with the perianal skin and anoderum by their external covering and location below the dental line. If the hemorrhoidal bag is blocked with a thrombus clot, they are painful.
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Internal hemorrhoids are located above the tooth line and are covered by the rectal column and perineal mucosa. They receive an additional rating on a 4-point scale
When choosing treatment for hemorrhoids, one must consider the size and severity of the disease, its impact on quality of life, the degree of pain it causes, the patient’s ability to adhere to the treatment and the patient’s personal desire.
No matter how severe, treatment almost always begins with a high-fiber diet and other lifestyle changes that affect bowel habits. This requires doctors to invest significant time in patient education, regardless of the type of illness or severity.
The treatments can be divided into three categories: conservative, office and surgery. Doctors must carefully discuss the options with the patient, emphasizing the advantages and disadvantages of each.
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Conservative methods are aimed at softening the stool, eliminating pain and correcting bad toilet habits. In most cases, the main driving factor is lifestyle, and unless patients change, they are more likely to relapse in the long run.
People take their phones to the bathroom and this habit is blamed for increasing the time spent in the bathroom and increasing pressure on the rectal area and strain during bowel movements. Some studies show a direct link between bathroom time and blood disorders, although an exact cause-and-effect relationship with cell phone use has not been established. In general, you should avoid spending too much time on dressing, including reading.
Hemorrhoid patients were reported to spend more time on the toilet and were more frequently and frequently strained than community and hospital controls.
Fiber draws water into the lumen of the large intestine, which increases the water content of the stool. The recommended daily fiber intake is about 28 grams for women and 38 grams for men.
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It is difficult to achieve a high level of intake without supplementation for people who eat a classic American diet with a lot of fast food.
In this meta-analysis, the relative risk of symptoms persisting or not improving with fiber supplementation was 0.53 (95% confidence interval [CI] 0.38–0.73) and the relative risk of bleeding was 0.50 (95% CI 0.28–0.89 ). Psyllium husk is an inexpensive bulk-forming fiber supplement; The optimal daily dose is unknown.
We recommend a fiber intake of at least 28 grams per day for women and 38 grams for men, for whom psyllium husk can be used as a dietary supplement.
Laxatives such as Docosta are used to change the consistency of the stool when there is an organic bowel problem rather than a food problem. These can be used as therapy to enhance the effects of fiber therapy.
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Local anesthesia (eg, 5% lidocaine) is often used to treat pain from minor wounds, but no reliable data have been published. Since most cases of hemorrhoids progress over time, no long-term improvement should be expected from local anesthesia. However, it can be used as an adjunctive treatment in selected cases where short-term improvement is the main goal, and we recommend it based on our experience.
Phlebotonics contains many ingredients including natural plant extracts such as flavonoids and synthetic products. Although the exact mechanism of action is unknown, phlebotonics are thought to increase circulation and drainage, normalize capillary permeability and reduce inflammation in the hemorrhoidal pads.
Although phlebotonics produce better results than placebo in the short-term control of hemorrhoids, long-term data are lacking. Therefore, the ASCRS practice guidelines offer a weak recommendation for routine use of these substances.
In a meta-analysis of 1,514 patients versus placebo, flavonoids (diosmin, hesperidin, rotoside) gave an advantage of the response in terms of bleeding (relative bleeding [RR] 0.33), pruritus (RR 0.65), and frequency (RR 0.53). ,
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Although preparation H is widely used as an over-the-counter drug, there is no good data on it and it is not considered a phlebutonic.
Office-based treatments – rubber ligation, infrared photocoagulation, and sclerotherapy – are often used for stages I, II, and III hemorrhoids that do not respond to conservative treatment. The main purpose of these treatments is to reduce blood flow to the hemorrhoidal sac.
Although office-based treatments are effective and serious complications are uncommon, recurrence rates can be high, requiring patients to receive additional treatments. In addition, septic complications can occur, so patients should be carefully monitored for fever and urinary problems. Pain is a common symptom after in-office treatments, and bleeding may also occur.
The ASCRS guidelines recommend office-based treatment for patients with stage I and II hemorrhoids, and for some patients with stage III hemorrhoids.
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Ligation of the apex of the hemorrhoidal pad stops the blood flow and the hemorrhoidal tissue undergoes necrosis (Figure 2). The ligation is done above the dental line, when the sensory nerve fibers are separated from those below the line; Therefore, the operation caused less pain than expected. One or more hemorrhoid pads may be tied at the same time, although increased pain, bleeding, and muscle reactions have been reported with multiple dressings during the same procedure.
Figure 2. In a rubber band, the internal artery is grasped with forceps (A) and drawn into the cylinder of ligation (B). A band is placed around the base of the hemorrhoid (C), which cuts off its blood supply and causes it to fall off within a few days.
The risk of bleeding after the procedure was nine times higher in patients taking warfarin, and the risk was three times higher in patients taking aspirin, so it is unclear whether patients who you take anticoagulant medication should receive this procedure.
This procedure has been found to be effective for stages I to III hemorrhoids, although some patients with stage III hemorrhoids may benefit more from excisional hemorrhoidectomy, which is associated with a lower recovery rate than ligation. rubber.
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A randomized controlled trial comparing hemorrhoidal vein ligation and rubber ligation for symptomatic hemorrhoids in 372 patients with stage II and II hemorrhoids. Pain scores decreased significantly with rubber band ligation on the first and seventh days after the procedure, but relapse was more common (49% vs. 30%,
In general, rubber band ligation is the best option for grade II hemorrhoids, as it is easy to perform, associated with low pain scores, and can be used to treat recurrences.
In this procedure, an infrared probe emits heat to cause coagulation, fibrosis, and eventually necrosis of the removed tissue.
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