Tackling haemorrhoids

The digestive system of our body is adapted to break down  food and absorb nutrients into our body. The food we swallow travels  through the tract and at the end of a 30 foot journey, the unabsorbed  food remnants are expelled from our body as stools or faeces. The wall  of the bowels form sphincters (valves) that serve as gateways to  passage of food particles. The anal canal, the lattermost part of the  digestive tract has two such valves, namely the external and internal  anal sphincters that aid in continence (stool control). In addition, the  mucosa and submucosa of the anal canal forms 3 anal cushions that serve  as an efficient fluid and gas-proof seal. These cushions are highly  vascular structures covered by a thin epithelium. Due to many reasons,  these anal cushions may become enlarged, giving rise to the condition  known as haemorrhoids or piles. These enlarged, congested cushions often  bleed and you will have to seek medical attention immediately.

Haemorrhoids  is a Latin term derived from the Greek word haimorrhois (haima-blood, rhoos-flowing).  In our community, most people refer to any abnormal lump or skin tag  felt at the anus as “piles”. It is important to know that a lump at the  anus or bleeding with defecation does not always mean that you are  suffering from haemorrhoids. Lumps may also occur in a more serious  conditions such as cancer (colorectal carcinoma), prolapsed rectum  (protrusion of the rectum through the anal orifice) andinflammatory  bowel disease as well non-threatening isolated skin tags. Consultation  of a general surgeon once you experience the symptoms will help timely  diagnosis, exclusion of colorectal cancer and apt treatment.   

Symptoms
Uncomplicated haemorrhoids are usually associated with  painless bleeding with defecation (passage of stools). Blood appears  bright red on toilet paper or may splash on to the lavatory pan if the  bleeding is heavy. The second symptom is a lump felt in the anus, following defecation and haemorrhoids are classified into 4 types accordingly.  

 
 First degree - No prolapse felt (lump). Only bleeding   
 Second degree - Piles prolapse but reduce spontaneously   
 Third degree - Piles prolapse. Reduction has to be done manually   
 Fourth degree – Piles permanently prolapsed   
In addition   

•     Itching due to leakage of mucus from the exposed mucosa onto the skin.   
•     Discomfort   
•    Pain (when complicated) is seen.   

These symptoms may vary with the individual’s diet, physical activity and psychological stress levels.   

What causes haemorrhoids?
The current understanding of it reveals that shearing  forces exerted on the anus cause mucosal trauma and the downward  displacement of these anal cushions distorting the supporting structures  lead to a loss of elasticity (the ability of an object to resume its  normal shape after being stretched), that causes failure to retract  following defecation. The shearing forces are generated as a result of  the following.   

•     Fibre-deficient diet (Prolongs gut transit time, forming smaller, harder stools that require a tremendous strain to expel)   
•     Presence of hard faecal mass in the rectum, obscuring blood flow, eventually causing congestion in the cushions   
•     Straining to pass stools and sitting on the lavatory for a  prolonged period of time (the habit of reading newspapers or gaming on  the mobile phone) adding to the congestion   
•     Holding the urge to defecate   
• Weakening of supportive muscular structures with ageing   
•     Low physical exercise causing reduced metabolism, thus delaying digestion   
•    Dehydration   

Haemorrhoids may occur in any age group but are extremely rare  in children. It is uncommon in individuals below the age of 30, although  women in that age category may develop it during pregnancy or after childbirth. 

Although both sexes are affected, there’s a slightly higher  incidence in men than in women. The occurrence in children is extremely  rare. 10 percent of the population experience symptomatic haemorrhoids  at some point of their lives. It is found to be more prevalent in  urban areas compared to rural and more in those with a higher  socio-economic status, that may be a result of dietary deficiency of  fibre. They are more common in individuals with raised abdominal  pressure (i.e. constipation, pregnancy, obesity).   

This condition has periods of relapse and  spontaneous resolution that may cause delayed presentation for medical  help. Some are reluctant to seek help as they find this condition mortifying. This is a benign disease condition that is often  repressed by the affected, fostering a significant negative impact on  their lives, as it causes constant physical and psychological discomfort,  such as lack of self-esteem and poor educational/work performance. The  pain during defecation makes the individual reluctant to pass stools  that further precipitates the condition. Early detection and treatment  avoids complications and relieves discomfort.   

Complications

• The bleeding should never be underestimated regardless of  the volume, as chronic blood loss with haemorrhoids often gives rise to  iron deficiency anaemia.   
•     Profuse haemorrhage   
•     strangulation (cut off of blood supply)   
•     thrombosis (blood clot)   
•     ulceration and gangrene (tissue death)   
•     fibrosis   

Diagnosis
 The diagnosis of haemorrhoids is made by a clinician based  on the symptoms and a digital rectal examination findings. In addition a  proctoscopy (the proctoscope is an apparatus that helps view the anal  cavity) is performed. The possibility of colorectal cancer should always  be excluded with performance of a sigmoidoscopy or colonoscopy. A small  percentage of haemorrhoids are associated with colorectal cancer.   

Management
The classification into different degrees helps decide on  the management plan. The initial intervention consists of conservative treatments  for those with first and second degree haemorrhoids. Conservative  measures include adding wholegrain bread and cereals (wheat, oats  barley and rye) , fruits, vegetables, nuts and legumes softens and  increases the bulk of stools allowing easier and less strenuous passage  owing to the high dietary fibre content (A daily minimum of 25g fibre  for women and 38g for men is recommended) An adequate amount of  water (at least 8 glasses per day) complements the high fibre diet. In  addition, stool softeners and bulking agents, evacuation of bowels only  when nature calls and adaptation of defecating positions help  minimize straining. Suppositories and various topical creams may  alleviate symptoms.   

If first and second degree haemorrhoids do not improve with  conservative measures, the surgeon proceeds with other non-operative  interventions such as sclerotherapy injections. For bigger piles,  ‘banding’ is a less common method used. Third and fourth degree piles,  second degree piles that do not respond to non-operative measures,  complicated external piles or severe bleeding causing anaemia require  surgical interventions such as haemorrhoidectomy.   Haemorrhoids are a benign condition resolved with prompt  medical care. It is important to seek help as soon as possible, to nip it in the bud and avoid complications. Since prevention is always better than cure, be mindful to incorporate high dietary fibre in meals, drink  plenty of water, exercise moderately to increase the basal metabolic rate  of the body, avoid prolonged sitting on the toilet and initiate  defecation only when you have the urge and avoid straining.