Haemorrhoids are a common cause of bleeding from the rectum. They are vascular structures in the anal canal, and in their normal state, they are cushions that help with stool control. They become pathological when swollen or inflamed. At this point the condition is technically known as haemorrhoidal disease.
The signs and symptoms of haemorrhoids depend on the type present. Internal haemorrhoids usually present with painless rectal bleeding, while external haemorrhoids may produce few symptoms. Some haemorrhoids become clotted (called thrombosed haemorrhoids), people can have significant pain and swelling in the area of the anus. Many people incorrectly refer to any symptom occurring around the anal-rectal area as “haemorrhoids” and serious causes of the symptoms should be ruled out. It must be pointed out that whilst most cases of fresh rectal bleeding are due to haemorrhoidal bleeding, any person over the age of 50 should be fully investigated with a colonoscopy, to prove that bleeding is not from bowel cancer.
Up to half of people may experience problems with haemorrhoids at some point in their lives. Outcomes are usually good. Piles (haemorrhoids) are swellings that can occur inside and around the back passage (anus) and the anal canal. The anal canal is the last part of the large intestine and is about 4 cm long. At the lower end of the anal canal is the opening to the outside (usually referred to as the anus), through which faeces pass. At the upper end, the anal canal connects with the rectum (also part of the large intestine). There is a network of small veins (blood vessels) within the lining of the anal canal. These veins sometimes become wider and engorged with more blood than usual. The engorged veins and the overlying tissue may then form into one or more small swellings called piles.
Internal haemorrhoids are those that form above a point 2-3 cm inside the back passage (anus) in the upper part of the anal canal. Internal piles are usually painless because the upper anal canal has no pain nerve fibres. External piles are those that form below that point, in the lower part of the anal canal. External piles may be painful because the lower part of the anal canal has lots of pain nerve fibres.
The terminology can be a little confusing – you would have thought that external piles would mean outside of the anal canal (and so outside of the anus) but this is not always the case. There are external piles that are actually inside the anus. Internal piles can also enlarge and drop down (prolapse), so that they hang outside of the anus. Some people develop internal and external piles at the same time.
Internal piles can be classified into grades 1 to 4 according to their severity and size:
- Grade 1 are small swellings on the inside lining of the anal canal. They cannot be seen or felt from outside the anus. Grade 1 piles are common. In some people they enlarge further to grade 2 or more.
- Grade 2 are larger. They may be partly pushed out from the anus when you go to the toilet, but quickly spring back inside again.
- Grade 3 hang out from the anus when you go to the toilet. You may feel one or more as small, soft lumps that hang from the anus. However, you can push them back inside the anus with a finger.
- Grade 4 permanently hang down from within the anus, and you cannot push them back inside. They sometimes become quite large.
CAUSE OF HAEMORRHOIDS
While the exact cause of haemorrhoids remains unknown, a number of factors which increase intra-abdominal pressure, in particular constipation, is believed to play a role in their development.
Anyone at any age can be affected by haemorrhoids. However, they are usually more common in elderly people and during pregnancy. Researchers are not certain what causes haemorrhoids. “Weak” veins – leading to haemorrhoids and other varicose veins – may be inherited. It’s likely that extreme abdominal pressure causes the veins to swell and become susceptible to irritation. The pressure can be caused by obesity, pregnancy, standing or sitting for long periods, straining on the toilet, coughing, sneezing, vomiting, and holding your breath while straining to do physical labour.
Diet has a pivotal role in causing – and preventing – haemorrhoids. People who consistently eat a high- fibre diet are less likely to get haemorrhoids, but those who prefer a diet high in processed foods are at greater risk of haemorrhoids. A low-fibre diet or inadequate fluid intake can cause constipation, which can contribute to haemorrhoids in two ways: it promotes straining on the toilet and it also aggravates the haemorrhoids by producing hard stools that further irritate the swollen veins.
SYMPTOMS OF HAEMORRHOIDS
Most cases of piles (haemorrhoids) are mild, and the symptoms often disappear on their own after a few days. Some people may not even realise they have haemorrhoids, as they do not experience symptoms. However, when symptoms do occur they may include:
- bleeding after passing a stool (the blood will be bright red)
- itchiness around your anus (the opening where stools leave the body)
- a lump hanging down outside of the anus, which may need to be pushed back in after passing a stool
- a mucus discharge after passing a stool
- soreness, redness and swelling around your anus
HOW DO I KNOW IF I HAVE PILES
First, your gastroenterologist will look at the anal area, perhaps by inserting a lubricated gloved finger. Your gastroenterologist may decide to use a proctoscope to examine the ano-rectal region.
If the bleeding occurs more than once or twice, most patients will require a definitive procedure called colonoscopy or flexible sigmoidoscopy under light sedation to identify internal haemorrhoids, and at the same time to rule out other ailments that frequently cause anal bleeding, such as anal fissure, colitis, Crohn’s disease. Colorectal cancer (or bowel cancer) must be excluded in people above the age of 50.
Initial treatment for mild to moderate disease consists of increasing fibre intake, oral fluids to maintain hydration, topical medicines to help with pain, and rest. A number of minor procedures may be performed if symptoms are severe or do not improve with conservative management. Injection of bleeding haemorrhoids by your Gastroenterologist or Surgeon can be useful in many cases to prevent further bleeding. Ask your doctor who is performing the colonoscopy if injection can be done whilst you are under sedation (ie. At the same time as your colonoscopy) to avoid pain during injection. It also avoids the need for repeat sedation for the purpose of injection at another time. In more recent years, gastroenterologists tend to use a medicine called “phenol in oil” to inject the haemorrhoids. This causes a scarring (fibrotic) reaction which obliterates the blood vessels going to the piles.
Banding is a procedure where a very tight elastic band is put around the base of the haemorrhoid to cut off its blood supply. The haemorrhoid should fall off after about a week. Surgery under general anaesthetic (where you are asleep) is sometimes used to remove or shrink large or external haemorrhoids but surgery is often the last resort.
PREVENTING RECURRENCE OF HAEMORRHOIDS
Once you know for certain that rectal bleeding is due to haemorrhoids, you can make lifestyle changes to reduce the strain on the blood vessels in and around your anus to prevent recurrent bleeding. These can include:
- gradually increasing the amount of fibre in your diet – good sources of fibre include fruit, vegetables, wholegrain rice, whole wheat pasta and bread, seeds, nuts and oats
- drinking plenty of fluid, particularly water, but avoiding or cutting down on caffeine and alcohol
- not delaying going to the toilet – ignoring the urge to empty your bowels can make your stools harder and drier, which can lead to straining when you do go to the toilet
- avoiding medication that causes constipation – such as painkillers that contain codeine
- losing weight if you are overweight
- exercising regularly – this can help prevent constipation, reduce your blood pressure and help you lose weight
If your stools are lumpy or if you suffer from constipation, you can ask your gastroenterologists for specific advice.
FOR MORE INFORMATION
Obtaining accurate and useful advice from an appropriately qualified Specialist (Gastroenterologist or Colorectal Surgeon) will prevent further long term problems and recurrent bleeding haemorrhoids. You may need further definitive investigation to rule out other sinister conditions. If you are above the age of 50, it is always recommended that rectal bleeding is further investigated rather than assumed to be from haemorrhoids.