Hemorrhoids are a disease characterized by varicose changes in the veins of the anus and rectum with the formation of hemorrhoidal nodes. Symptomatic symptoms include burning sensation, heaviness, itching in the anus, bleeding of scarlet blood from the nodes. Can be complicated by prolapse, impingement, and thrombosis of the hemorrhoidal nodes. Inflammation of the nodes leads to rectal fistulas and paraproctitis. Prolonged hemorrhoidal bleeding leads to anemia.
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Hemorrhoids are one of the most common proctologic diseases. Hemorrhoids are pathologically enlarged hemorrhoidal nodes that are prone to inflammation, bleeding and falling out of the anus. The name of the disease is a Greek term meaning bleeding. Bleeding is the most prominent, but not the only symptom in the development of hemorrhoids.
Hemorrhoidal venous plexuses in humans are located in the submucosal layer of the anal canal wall, are similar in structure to the cavernous bodies of the genitals, and are believed to play a role in ensuring complete closure of the anus and retention of feces. A distinction is made between internal and external hemorrhoids. Most people sooner or later have varying degrees of enlargement of these venous formations. Enlargement of hemorrhoids, detected during examination and not accompanied by clinical symptoms, is not considered a disease.
Clinically, hemorrhoids are manifested by prolapse of internal hemorrhoids, thrombosis of external ones, bleeding, itching and burning in the rectum, and painful defecation. Currently, in Russia, surgical removal of pathologically enlarged knots is applied in 75% of cases (in comparison, in the USA and Europe, this figure is about 20% of cases). Early detection of the disease and timely visit to the doctor contributes to the effectiveness of non-surgical methods of treatment.
Causes of hemorrhoids
A pathogenetic factor in the development of hemorrhoids is impaired blood circulation in the hemorrhoidal venous accumulations, which contributes to the development of dystrophic changes in the connective tissue and muscle structures that fasten the nodes inside the anal canal. The following factors contribute to the development of the disease: a tendency to stool disorders (frequent constipation or diarrhea), sedentary lifestyle, abuse of spicy food and alcohol.
Occupational factors include occupations that require prolonged sitting (drivers, pilots, etc.). In addition, some sports such as horseback riding, cycling, and weightlifting can contribute to poor blood circulation in the perianal area. Pregnancy and childbirth can also contribute to hemorrhoids in women.
There are acute and chronic hemorrhoids, which are essentially stages of the same disease. There are also internal hemorrhoids, external hemorrhoids and combined hemorrhoids. There are four stages in the clinical course of hemorrhoids.
The first stage is characterized by periodic discharge of scarlet blood from the anus. No prolapse of hemorrhoidal nodes is noted.
In the second stage, hemorrhoidal nodes fall out and push them back in on their own. Can be accompanied by bleeding, and proceed without it.
In the third stage, the prolapsed hemorrhoidal nodes do not self-repair and must be returned to the anal canal by hand. Bleeding may also be present or absent.
Stage four hemorrhoids are characterized by the inability to reposition hemorrhoids that constantly fall out of the anal canal. A distinction is also made between acute and chronic hemorrhoids.
Symptoms of hemorrhoids
Acute hemorrhoids are clinically manifested by thrombosis of the external hemorrhoidal nodes, or by thrombosed internal nodes falling out of the anal canal. Thrombosis of the hemorrhoidal nodes is characterized by significant enlargement and thickening of the nodes, and the nodes cause rather intense pain (proctalgia), especially during defecation.
The main clinical signs of chronic hemorrhoids are bleeding episodes from the anus, itching and burning sensation in the perianal area, periodic prolapse of the internal hemorrhoid nodes. Tight closure of the anus sphincter and persistent prolapse of the hemorrhoidal nodes may contribute to transparent mucous discharge from the anus.
Bleeding is a very common sign of hemorrhoids and it is estimated that 10% of the population has recurrent episodes of bleeding from the anus. In 70-80% of cases, hemorrhoids are the cause of this bleeding. However, most patients do not seek medical help because the bleeding is sparse and infrequent, and they do not pay much attention to it. In addition, many are embarrassed to go to a proctologist or are afraid of the examination methods.
Hemorrhoidal bleeding usually occurs during defecation, It can be scarlet splashes when you urinate or traces of blood on paper. If blood remains in the rectum after defecation, it will come out as dark clots next time.
Prolonged hemorrhoids are manifested by the prolapse of the internal hemorrhoidal nodes. Initially, the nodes fall out when you push during defecation. Later on, with progression of the disease, the nodes fall out more frequently, when coughing or sneezing. They don’t fall out on their own, but have to be manually redirected. Over time, the prolapse becomes permanent, and cannot be repositioned. Hemorrhoids that fall out can be very uncomfortable, and are prone to thrombosis. Often hemorrhoids are accompanied by anal itching due to constant irritation of the skin in the anus area with secretions.
Despite the rather uncomplicated diagnosis of this disease, it is worth taking it seriously, because insufficient examination can lead to misdiagnosis and failure to detect significant complications or concomitant pathologies.
Proctologic examination. Patients with suspected hemorrhoids are examined in a gynecological chair with the knees maximally brought to the abdomen, or in the lap-octave position. An external examination of the anus and perianal area is performed, noting the shape of the anus, existing deformities, scarring, fistulas, and a gaping anus. You pay attention to the color and condition of the skin, assess the severity of external hemorrhoidal nodes, note the degree of prolapse of internal ones, as well as the possibility of their retraction. The anal reflex is checked by stroking the perianal area with a probe. Then the edges of the anus are dilated and the walls of the anal canal are examined for the presence of an anal fissure.
Finger examination of the rectum. After external examination, a finger examination of the rectum is performed, noting the condition of the external and internal anal sphincters, their tonic tension, strength of volitional contractions, and degree of painfulness. The mucous membrane of the canal is examined for the presence of defects, anal polyps and scars. Often, accurate determination of the localization and size of hemorrhoidal nodes during palpation examination may present a certain difficulty due to the fact that the nodes decrease in size during palpation. Therefore, the patient is advised to push to identify and examine the nodes more clearly during the examination.
Methods of visualizing the bowel. About 8-12 cm of the anal canal can be examined in detail during anoscopy. This examination is fairly well tolerated by patients and allows the area where the internal hemorrhoids are located to be examined. Internal hemorrhoidal nodes can fall out through the lumen of the anoscope if the patient is straining. Rectomanoscopy is prescribed for all patients with suspected hemorrhoids. If it is not possible to perform a rectomanoscopy up to 25 centimetres, or if there is suspicion of pathologies of the upper parts of the large intestine, an irrigoscopy or colonoscopy is performed.
Additional diagnostics. Ultrasound of the abdominal organs allows to exclude or identify concomitant diseases of the digestive tract. Gastroscopy is prescribed to rule out upper digestive system hemorrhage.
Practice shows that a third of hemorrhoids patients have diseases of the anal canal and large intestine, some of which may also be the cause of bleeding from the anus. It is not uncommon for a hemorrhoid examination to diagnose rectal cancer.
Treatment tactics for hemorrhoids is chosen based on the stage of the disease. Drug treatment is often limited to the first and second stages of the disease, in the acute period of the disease. When conservative treatment is prescribed a diet that promotes normalization of stool with frequent diarrhea and its softening with difficult defecation. If necessary, prescribe laxatives. As a general therapy, drugs that help to strengthen the venous walls (phlebotropic agents – diosmin) are also recommended. Locally used suppositories and ointments with anti-inflammatory, healing, analgesic, styptic and improving local blood flow.
The prescription of local medications depends on the severity of certain symptoms. Most often, polycomponent agents are chosen, which include anti-inflammatory, anesthetic and hemostatic elements. Means containing anti-inflammatory drugs (corticosteroids and nonsteroidal drugs) are prescribed in short courses to avoid side effects. An effective hemostatic agent, sodium alginate, is used for severe bleeding.
Conservative therapy for hemorrhoids is aimed at alleviating clinical symptoms and attenuating exacerbations. It should be remembered that this is symptomatic therapy, which does not lead to the elimination of the disease and is temporary in nature. A tendency to a sedentary lifestyle or excessive physical activity contributes to the development of new exacerbations and progression of hemorrhoids.
Minimally invasive methods
Effective measures to cure hemorrhoids in the early stages are minimally invasive techniques to remove hemorrhoidal nodes. For first and second stage hemorrhoids, sclerotherapy, infrared coagulation, radiotherapy) is performed. Often in practice, combined treatment is used. Despite the high degree of safety and convenience for patients, minimally invasive techniques are not always applicable. Ligation with latex rings can be effective at the second and third stages. Removal of hemorrhoids by laser (depending on the technique and volume of intervention) is carried out for any degree of hemorrhoids.
Radical surgery for hemorrhoids is shown in the third and fourth stages of the disease. Taking into account the clinical situation, surgical removal of hemorrhoidal nodes (hemorrhoidectomy by Milligan-Morgan) is performed. In this case the cavernous venous plexuses are excised as a whole, excluding the possibility of recurrence of the disease. Stapler hemoroidopexy according to Longo, operations in Ferguson and Parks modifications are also possible. Modern technologies of interventions for hemorrhoids imply use of electrosurgical instrument LigaSure, ultrasonic scalpel. The latest approaches allow reducing the postoperative period and excluding probable complications as much as possible.
Since hemorrhoids are not life-threatening disease, in all cases, except for persistent bleeding, resulting in severe anemia, the patient decides on the advisability of surgical intervention, depending on the doctor’s recommendations. As patients with frequent exacerbations usually seek medical help, hemorrhoids cause them discernable inconveniences and greatly impair the quality of life, the proctologist’s task is to examine the patient carefully and to recommend the optimal treatment method.
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