Hemorrhoids- definition, considerations, 
causes, classification, diagnosis, therapies.

Definition of hemorrhoids:

• Abnormally large of painful conglomerates of blood vessels, supporting tissues and overlying mucus membrane or skin of the anorectal area.

• Bright red bleeding on the surface of the stool, on the toilet tissue and/or in the toilet bowl.

General considerations:

In the industrial countries, hemorrhoidal disease is extremely common.

Although most individuals may begin to develop hemorrhoids in their 20's, hemorrhoidal symptoms usually do not become evident until the 30's. Estimates have indicated that 50% per cent of men over 50 years of age have symptomatic hemorrhoidal disease and up to 1/3 of the total US population have hemorrhoids to some degree.

 

Causes:

The causes of hemorrhoidal disease are similar to those which cause varicose veins, i.e., genetic weakness of the veins, excessive venous pressure, pregnancy, long periods of standing or sitting and heavy lifting are considered the minor factors.

Because the venous system supplying the rectal area contains no valves, factors which increase venous congestion in the region can precipitate hemorrhoid formation. This includes increasing intra-abdominal pressure (e.g., defecation, pregnancy, coughing, sneezing, vomiting, physical exertion and portal hypertension due to cirrhosis), a low fiber diet induced increase in straining during excretion and standing or sitting for prolonged periods of time.

This increasingly common affliction is caused by stagnation and coagulation of blood fibron in the tiny capillaries that feed the anus and lower rectum; this is mainly the result of sticky toxic waste in the blood stream, owing to excess consumption of  refined starch, especially white bread and other flour products; in addition to dietary adjustments, daily practice of the anal sphincter exercise and defecation in the squatting position help correct and cure this condition.

Classification of hemorrhoids:

Hemorrhoids are typically classified according to location and degree of severity.

External hemorrhoids occur below the anorectal line, the point in the 3-cm-long anal canal at which the skin lining changes to mucous membrane. They may be either full blood clots (thrombotic hemorrhoid) or connective tissue (coetaneous hemorrhoid). A thrombotic hemorrhoid is produced when a hemorrhoidal vessel has ruptured and formed a blood clot (thrombus), while a coetaneous hemorrhoid consists of fibrous connective tissue covered by anal skin. Coetaneous hemorrhoids can be located at any point on the circumference of the anus. Typically, they are caused by the resolution of a thrombotic hemorrhoid, i.e., the thrombus becomes organized and replaced by connective tissue.

Internal hemorrhoids occur above the anorectal line. Occasionally, an internal hemorrhoid will enlarge to such a degree that it will prolapse and descend below the anal sphincter.

Internal-external, or mixed, hemorrhoids are a combination of contiguous external and internal hemorrhoids that appear as baggy swelling. The following types occur:

• Without prolapse- bleeding may be present, but there is no pain.

• Prolapsed- characterized by pain and possible bleeding.

• Strangulated- the hemorrhoid has prolapsed to such a degree and for so long that its blood supply is occluded by the anal sphincter's constricting action. Strangulated hemorrhoids are very painful and usually become thrombosed.

 

Diagnosis:

The symptoms most often associated with hemorrhoids include itching, burning, pain, inflammation, irritation, swelling, bleeding and seepage. Itching is rarely due to hemorrhoids except when there is mucous discharge from prolapsing internal hemorrhoids.

The common cause of anal itching include tissue trauma secondary to excessive use of harsh toilet paper, is Candida albicans, parasitic infection and allergies.

Pain does not occur unless there is acute inflammation of external hemorrhoids. As there are no sensory nerves ending above the anorectal line, uncomplicated internal hemorrhoids rarely cause pain.

Bleeding is almost associated with internal hemorrhoids and may occur before, during or after excretion. When bleeding occurs from an external hemorrhoid, it is due to rupture of an acute thrombotic hemorrhoid. Bleeding hemorrhoids can produce severe anemia due to chronic blood loss.

Therapy:

Dietary factors

In contrast to the westernized countries, hemorrhoids are rarely seen in parts of the world where high fiber, unrefined diets are consumed. A low fiber diet, high in refined foods, contributes greatly to the development of hemorrhoids.

Individuals consuming a low fiber diet tend to strain more during bowel movements since their smaller and harder stools are difficult to pass. This straining increased the pressure in the abdomen which obstructs venous return. The increased pressure will increase pelvic congestion and may significantly weaken the veins, causing hemorrhoids to form.

A high fiber diet is perhaps the most important component in the prevention of hemorrhoids. A diet rich in vegetables, fruits, legumes and grains promotes peristalsis and many fiber components attract water and form a gelatinous mass which keeps the feces soft, bulky and easy to pass. The net effect of a high fiber diet is significantly less straining during defecation.

Bulking agents

Natural bulking compounds can be used to reduce fecal straining. They are the first basic step in your preventative strategy. These fibrous substances, particularly Psyllium seed and guar Guam, possess mild laxative action due to their ability to attract water and form a gelatinous mass. They are generally less irritating than wheat bran or other cellulose fiber products. Several double-blind clinical trials have demonstrated that supplementing the diet with bulk-forming fibers can significantly reduce the symptoms of hemorrhoids (bleeding, pain, pruritis and prolapse) and improve bowel habits.

Hydrotherapy

The warm Sitz bath is an effective non-invasive treatment for uncomplicated hemorrhoids. A Sitz bath is a partial immersion bath of the pelvic region. The temperature of the water in the warm Sitz bath should be between 100-105 F or 37.7-40.5 C.

Topical therapy

Topical therapy, in most circumstances, will only provide temporary relief. Topical treatment involve the use of suppositories, ointments and anorectal pads. Many over the counter products for hemorrhoids contain primarily natural ingredients, such as witch hazel, shark liver oil, cod oil, cocoa butter, Peruvian balsam, zinc oxide, live yeast cell derivative and allantoin.

Monopolar direct therapy

The Monopolar direct current technique is purely an outpatient procedure. No anaesthetic is needed, except local anaesthetic for the occasional hypersensitive or nervous patient. To date, there have been no reported cases of adverse effects, which speaks well for the procedures safety.

The Monopolar direct current technique for hemorrhoid management is fast becoming a treatment of choice in the United States. According to an article in Gastrointestinal Endoscopy, "this painless outpatient treatment of all grades of hemorrhoids is effective and safe. This methodology warrants consideration as the treatment of choice of hemorrhoidal disease.

The first published work on Monopolar direct current (also called inverse galvanism) was Obliteration of Hemorrhoids with Negative Galvanism by Wilbur E. Keesey MD of Chicago. Dr. Keesey dated the first use of this approach to 1897, although the technical problems (producing a smooth uninterrupted galvanic current source) were not worked out until approximately 1925. The technique then began to be used in general practice.

When indicated, the Monopolar direct current method, specifically designed for hemorrhoid treatment, will give permanent results. This technique is especially useful in advanced hemorrhoidal disease.

Treatment

As with all diseases, the primary treatment of hemorrhoids is prevention.

This involves reducing those factors which may be responsible for increasing pelvic congestion- straining during defecation, sitting or standing for prolonged periods or time or underlying liver disease. A high-fiber diet is crucial for the maintenance of proper bowel activity, and nutrients and botanical substances which enhance the integrity venous structures may also be of benefit.

A high carbohydrate diet rich in dietary fiber is indicated. The diet should contain liberal amounts of proanthocyanidin- and anthocyanidin foods such as blackberries, cherries, blueberries, etc., to strengthen vein structure. Alcohol and spicy foods should be removed as much as possible, as evidence indicates that continuous persistence of hemorrhoids when these two elements are present in the diet. Squatting while defecating, plus fasting and internal cleansing therapies are highly recommended in the long run, as is the external application of aloe vera in cases of continuous bleeding or itching.

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