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Introduction

Hemorrhoids are caused by swelling of the hemorrhoidal veins present in the last part of the intestine (rectum and anal canal) which take on an appearance similar to varicose veins. Hemorrhoids can be caused by various factors (such as efforts made during bowel movement or increased intra-abdominal pressure during pregnancy) but the cause is often not known.

Hemorrhoids can be internal (ie located inside the rectum) or external, in the mucous membrane surrounding the anus. They are very common: it is estimated that about 50% of the adult population suffers from ailments related to hemorrhoids from time to time.

Generally, hemorrhoids cause no problems; in some cases, however, they can cause itching, pain and bleeding. Rarely, blood clots can form inside the hemorrhoids: in this case we speak of thrombosed hemorrhoid. Thrombosis of a hemorrhoid is manifested by severe pain and intense itching.

In most cases, the ailments caused by inflammation of the hemorrhoids can be relieved by home remedies and lifestyle changes. In severe cases, surgical treatment can be used.

Don't assume that rectal bleeding is due to hemorrhoids. It is advisable to always contact your family doctor if you notice blood loss during, or at the end of the bowel evacuation or if the itching and pain do not go away within a short time with the drugs or ointments recommended by the pharmacist.In case of severe rectal bleeding it is advisable to go to the emergency room as soon as possible.

Causes

The causes of hemorrhoids are unclear. Their swelling may depend on an increase in pressure inside the abdomen caused by various factors:

  • efforts made during bowel evacuation
  • sitting on the toilet for a long time
  • obesity
  • pregnancy

Constipation, chronic diarrhea, and a low-fiber diet can promote the appearance of hemorrhoids. Advancing age also contributes to their development as the tissues that support the blood vessels in the anus and rectum tend to weaken and relax.

Symptoms

Many people have hemorrhoids without knowing it because they don't feel any discomfort. Others, however, manifest various disorders (symptoms) such as:

  • painless bleeding during bowel evacuation, Small traces of blood may occur on the toilet paper or in the toilet
  • irritation and itching in the anal region
  • anal pain
  • swelling of the anal region
  • nearby sore and painful lump to the anus (it could be a thrombosed hemorrhoid, ie in which a blood clot has formed)

The disorders caused by hemorrhoids generally depend on the location of the same:

  • internal hemorrhoids, located inside the rectum, are not seen or heard and rarely cause disturbances. But the strain and irritation during evacuation can damage the surface and cause bleeding. Sometimes the effort can push an "internal hemorrhoid through the" opening of the anus: in this case we speak of protruding or prolapsed hemorrhoid, which can cause pain and irritation
  • external hemorrhoids, located under the mucous membrane surrounding the anus when they become inflamed they can cause itching or bleeding. A typical complication of external hemorrhoids is the formation of a blood clot (thrombus) inside the hemorrhoidal vein (thrombosed hemorrhoid).The clot impairs normal blood circulation. In this case, swelling is noted in the anal region and the lump becomes severely painful

Diagnosis

The assessment (diagnosis) of hemorrhoids can be done by the family doctor through rectal examination. The doctor examines the area around the anus to see if there are any visible hemorrhoids. He can also perform an examination of the inside of the rectum, wearing gloves and introducing a lubricated finger to check for hemorrhoids. The digital rectal exam does not cause pain, only discomfort.

In some cases, visual observation of the anal area and digital rectal examination are not sufficient to ascertain the presence of hemorrhoids and it is necessary to use an instrument, called anoscope, which allows you to view the anal canal and the last section of the large intestine (rectum). L"anoscope it is a rigid tube, about 7-8 centimeters long with a light source at the end, which is inserted into the rectum after applying an anesthetic ointment.

As a precaution, your doctor may prescribe more in-depth tests, such as colonoscopy, to rule out the presence of colorectal cancers.

Through visual inspection of the anus, digital rectal examination and anoscopy, it is possible to determine the type of hemorrhoids, which can be internal, ie located in the upper two thirds of the anal canal, or external, ie placed in the third lower, near the anus. Hemorrhoids are also classified according to their size and severity:

  • first degree hemorrhoids, only internal and not visible, they can bleed, but they do not cause pain
  • second degree hemorrhoids, increased in volume, may protrude from the anus during bowel evacuation, but spontaneously re-enter
  • third degree hemorrhoids, consisting of one or more protruding (prolapsed) nodules that can be retracted manually
  • fourth degree hemorrhoids, they consist of larger nodules that protrude from the anus and cannot be retracted manually

The doctor prescribes a therapy according to the type and size of the hemorrhoids.

Prevention

Prevention of hemorrhoids consists, first of all, in changing eating habits. To keep the stool soft and prevent constipation it is recommended to:

  • increase the amount of fiber in the diet, eat more fruits, vegetables and whole grains
  • drink a lot of water, at least 6/8 glasses a day
  • take fiber-based dietary supplements if you have constipation problems or have trouble passing regular bowel movements
  • avoid efforts during evacuation, trying to keep the stool soft through a diet rich in fiber and the right amount of fluids
  • maintaining an active lifestyle, practicing regular physical activity and avoiding sitting for long

Therapy

Treatment of hemorrhoids depends on the degree of the hemorrhoids and the disorders they cause.

Do-it-yourself remedies

To relieve the discomfort and swelling caused by hemorrhoids, tricks and lifestyle changes are often sufficient:

  • increase the consumption of foods rich in fiber, such as fruits, vegetables, and whole grains, to make stools softer and to avoid straining during defecation
  • carry sitz baths, i.e. sit for 5-10 minutes on a basin containing warm water placed on the toilet or bidet
  • use moist toilet paper or wet wipes without perfume or alcohol, specific for anal hygiene
  • use local treatments such as creams or suppositories, recommended by the pharmacist
  • use pain relieving medications, only on the advice of a doctor or pharmacist. Among them: paracetamol, aspirin or ibuprofen (NSAIDs)

If, despite treatment, the burning and discomfort persist, or if the pain or bleeding is severe, consult your doctor.

Thrombosed external hemorrhoids

If a blood clot (thrombus) has formed inside an external hemorrhoid, your doctor can remove it with a simple incision and drainage, immediately relieving the pain. This procedure is most effective if performed within 72 hours of thrombus formation.

Minimally invasive procedures

If the pain or bleeding lasts over time, the doctor may recommend some minimally invasive procedures that can be done in the clinic under local anesthesia.

    • ligation of hemorrhoids with elastic band (elastic binding). Internal hemorrhoids can be tied with rubber bands that prevent the blood supply and cause the hemorrhoid to fall out within a week, without causing pain. Multiple treatments may be needed to get rid of all hemorrhoids. Elastic hemorrhoid ligation can cause bleeding, which may begin two to four days after the procedure, but is rarely serious. In very rare cases this procedure can cause complications such as severe thrombosis of the hemorrhoids, severe pain, abscesses and perianal fistulas.
    • hemorrhoid sclerotherapy, The doctor injects a hardening (sclerosing) chemical solution into the hemorrhoids to make them shrink. The injection is generally not painful but may be less effective than a bandage
    • photocoagulation of hemorrhoids (infrared, laser, or bipolar light), hemorrhoid coagulation techniques use heat, infrared light, or laser. Photocoagulation has few undesirable effects and does not cause major disturbances, but is less effective than elastic band ligation. The hemorrhoids, in fact, could recur (relapse)

Hemorrhoid surgery

If the hemorrhoids are too large and the treatments described above have not been successful, it is necessary to resort to surgery, in day hospital or in hospital.

The surgical procedures are:

  • hemorrhoidectomy, the surgeon removes the excess tissue that is causing the bleeding, through various techniques. The operation can be performed under local anesthesia and sedation, with spinal anesthesia or under general anesthesia. Hemorrhoidectomy is the most effective and complete treatment for the treatment of severe or relapsing hemorrhoids. Among the most frequent complications of the surgery are difficulties in emptying the bladder (urinary retention) and, consequently, urinary tract infections. Some people feel pain after the operation: in this case they are given pain medications (analgesics)
  • ligation of hemorrhoidal arteries, it is a surgical treatment that aims to reduce the blood supply to the hemorrhoids. It is usually carried out under general anesthesia, using an ultrasound probe introduced into the anus. The probe, through high-frequency sound waves, allows the surgeon to locate the blood vessels that supply the hemorrhoid. Each blood vessel is closed to block the flow of blood to the hemorrhoid which, therefore, shrinks within a few days. The ligation of the hemorrhoidal arteries is a safe and effective alternative to the surgery hemorrhoidectomy or hemorrhoidopexy. It is less painful and allows for faster recovery than other techniques. Side effects include bleeding and pain during evacuation or prolapse of the treated hemorrhoid. These disorders, however, usually improve within a few weeks
  • hemorrhoidopexy with mechanical stapler, a surgical technique that blocks the blood supply to the hemorrhoidal tissue and is usually used to treat prolapsed internal hemorrhoids.In general, hemorrhoidopexy causes less pain than hemorrhoidectomy and allows a faster return to usual activities. Compared to hemorrhoidectomy, hemorrhoidopexy with mechanical stapler is associated with a higher risk of hemorrhoids returning (recurrence) and rectal prolapse, a condition in which part of the rectum protrudes from the anus. Complications of hemorrhoidopexy can include bleeding, urinary retention, pain and, rarely, a blood infection (sepsis). The treating physician or surgeon will be able to recommend the most suitable surgical option for each person

Bibliography

Trompetto M, Clerico G, Cocorullo GF, Giordano P, Marino F, Martellucci J, Milito G, Mistrangelo M, Ratto C. Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement [Sintesi] Techniques in Coloproctology. 2015; 19: 567-75

In-depth link

Steven R. Brown, Haemorrhoids: an update on management. Therapeutic Advances in Chronic Disease. 2017; 8: 141–147

Cocorullo G, Tutino R, Falco N, Licari L, Orlando G, Fontana T, Raspanti C, Salamone G, Scerrino G, Gallo G, Trompetto M, Gulotta G. The non-surgical management for hemorrhoidal disease. A systematic review. Journal of Surgery. 2017; 38: 5-14

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