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Case 048:
Hemorrhoids: 1/7
Hemorrhoids.
Author:
David C Chung MD, FRCPC
Affiliation:
The Chinese University of Hong Kong
Mr. RCR was a 43 year old accountant who presented to his family doctor
complaining of rectal bleeding. His history went back about 7 weeks when he noticed
there were streaks of bright red blood coating his stool and spots of blood on the
toilet paper from time to time. There was also an embarrassing itch around his anus
on many days. He was sure it was a case of hemorrhoids and he medicated himself
daily with a suppository obtained from the local pharmacy. The condition seemed to
have improved but he was alarmed by an unusually large smear of bright red blood
on the toilet paper on the morning of his visit. The bleeding was not associated with
pain. Further questioning revealed that he moved his bowel no more than 3 times a
week, going to the toilet only when he felt the urge to go. Some degree of straining
was always required and consistency of the stool was firm but not hard. There was
no change in bowel habit and no family history of colonic cancer. He has always
enjoyed good health.
1. What are the possible causes of rectal bleeding?
This patient’s chief complaint was painless bleeding of bright red blood per
rectum and he concluded that it was a case of hemorrhoids. He may very well be
correct; blood shed by hemorrhoids is typically bright red because of arteriovenous communications in the hemorrhoid complex. But patients’ description of
blood in the stool is typically unreliable. As physicians, one should not overlook
other possible causes of rectal bleeding. Many diseases of the lower
gastrointestinal tract can present as blood of varying redness mixed with stool.
They include neoplasm, diverticular disease, inflammatory bowel disease
(ulcerative colitis, Crohn’s disease), angiodysplasia. Even blood from the upper
gastrointestinal tract can appear red if the bowel transit time is fast. In addition,
hemorrhoids should be differentiated from rectal and anal varices found in
patients with portal hypertension. Hemorrhoids and rectal/anal varices are
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different entities. Previous believe that hemorrhoid can arise from portal
hypertension and porto-systemic shunt is incorrect.
2. How should patients with suspected hemorrhoids be investigated?
Besides taking a relevant history from and performing a thorough physical
examination on the patient, a careful anorectal evaluation by digital examination
is warranted. While inspection of the lower gastrointestinal tract by anoscopy and
flexible sigmoidoscopy is indicated in all patients, complete colonic evaluation by
air-contrast barium enema or colonoscopy is reserved for patients in whom
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Rectal bleeding is atypical for hemorrhoids.
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Bleeding from hemorrhoids is not confirmed by anorectal examination.
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There are alarm features suggesting colonic neoplasm, which include:
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Age over 50 years.
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First degree relative with history of colon cancer.
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Change of bowel habits.
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Weight loss.
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Iron deficiency anemia from chronic blood loss. Anemia due to
hemorrhoids is rare.
Progress of the case—Examination of the patient revealed a middle age man looking
his age, well nourished, and relaxed. His vital signs were normal; no abnormalities
were found on examination of the cardio-respiratory system and abdomen. The anal
margin was smooth and nothing was observed to have prolapsed from within. The
wall of the anal canal was smooth to palpation; the sphincter tone was normal; no
lump was palpable in the rectum; the prostate was normal in size, shape,
consistency and mobility; no blood or mucus was observed on the glove of the
examining finger. An internal hemorrhoid with fresh bleeding point was observed at 3
o’clock just above the pectinate line through the anoscope. Result of flexible
sigmoidoscopy was normal.
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3. What are hemorrhoids?
In the anal canal, there are submucosal
cushions made up of vascular plexuses,
connective tissue, and smooth muscle fibers
typically located in the right anterior, right
posterior, and left lateral positions—
although these positions may be variable.
Internal hemorrhoids arise from congestion
and dilatation of veins in these cushions
above the pectinate line; they are covered
by columnar or transitional epithelium.
External hemorrhoids arise from congestion and dilatation of veins below the
pectinate line; they are covered by anoderm. Internal hemorrhoids are further
divided according to their degree of prolapse:
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First degree internal hemorrhoids bleed but do not prolapse.
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Second degree internal hemorrhoids bleed as well as prolapse through
the anal margin but the prolapse reduces spontaneously.
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Third degree hemorrhoids bleed and prolapse but the prolapse requires
manual reduction.
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Fourth degree hemorrhoids bleed as well as prolapse and the prolapse is
irreducible by manual manipulation.
4. What are the clinical features of hemorrhoids?
Internal hemorrhoids
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The commonest presentation of internal hemorrhoids is painless rectal
bleeding. Fresh blood that appears bright red may smear toilet paper, drip
into the toilet bowl, or coat the surface of stool. Dark old blood or blood
mixed in with the stool would suggest a more proximal bleeding site. The
blood from hemorrhoids is bright red because there are arterio-venous
communications within the complex.
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First degree internal hemorrhoids do not prolapse outside the anal margin.
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Second degree internal hemorrhoids can present as mucous-membranelined protrusions at the anal margin when the patient is asked to bear
down.
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Chronically prolapsed internal hemorrhoids can cause muco-fecal staining
of underwear.
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Pruritis ani is a common complaint in patients with hemorrhoids.
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Pain is unusual and may suggest thrombosis, incarceration, and even
strangulation.
External hemorrhoids
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A thrombosed external hemorrhoid is an exquisitely tender, bluish-black
nodule at the anal margin during the acute phase.
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If ignored the clot within reorganizes and the patient is left with a skin tag
at the anal margin.
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Crevices associated with skin tags can render the maintenance of hygiene
difficult, leading to development of reactive dermatitis.
5. What factors can promote the development of hemorrhoids?
Factors that lead to increase in abdominal pressure and straining can promote
the development of hemorrhoids:
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Chronic constipation.
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Straining during defecation; this can occur with constipation as well as
diarrhea.
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Prolonged sitting at the toilet.
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Obesity.
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Pregnancy.
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Holding back against urge to defecate.
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Sedentary lifestyle.
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Anal intercourse.
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6. How should hemorrhoids be managed?
Uncomplicated chronic first, second, and some third degree hemorrhoids can be
treated conservatively by medical therapy.
Medical therapy
o Treat constipation. (This topic was fully discussed in Case of the Week 034,
http://www.medicine-on-line.com and is summarized below).
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Develop a regular bowel habit.
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Increase daily fiber intake to 20 – 30 grams.
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Increase non-caffeinated, non-alcoholic fluid consumption to at least 8
glasses per day.
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Increase daily physical activity.
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Avoid constipating medications.
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Use only safe laxatives like fiber supplements (e.g. psyllium) or stool
softener (e.g. docusate).
o Advise patient to go to the toilet in a timely fashion. Holding back against urge
to defecate promotes straining.
o Discourage patient from spending unnecessary time (e.g. reading) while
sitting at the toilet. Sitting at the toilet for long periods also promotes straining.
o Prescribe regular sitz bath (sitting and bathing in a tub of warm water). It
relieves irritation and improves perineal hygiene.
o Anal suppositories (e.g. bismuth subgallate) are helpful. Hydrocortisone may
be added for its anti-inflammatory effect but should be restricted to short term
use only. Long term dependence on steroid containing compounds can result
in fungal supra-infection.
Hemorrhoids that failed medical therapy, advanced hemorrhoids, and
hemorrhoids complicated by thrombosis should be referred to a colorectal
surgeon. A number of office procedures are available for the treatment of
hemorrhoids.
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Office procedures
The following office procedures have the advantage of simplicity. But selection of
patients and performance of the procedure require expertise and should not be
undertaken by the inexperience.
o Elastic band ligation is a technique in which a rubber band is placed around
the base of redundant hemorrhoid tissue with a special applicator. After a
week to 10 days, the hemorrhoid sloughs off and scarring fixes the residual
tissue to the rectal wall. This method is applicable only to internal hemorrhoids
above the pectinate line covered by insensitive rectal mucosa. The patient will
experience significant pain if the elastic band is applied to hemorrhoids in the
transitional zone or below where the anoderm is richly supplied with nerve
endings.
o Injection sclerotherapy is another technique used to treat internal hemorrhoids.
A sclerosing solution is injected submucosally above the hemorrhoid complex
to set off an inflammatory reaction that leads to scarring and re-attachment of
redundant tissue to the rectal wall.
o Infrared photocoagulation is a third office-based procedure but it is not
suitable for large hemorrhoids with a significant amount of prolapse.
o Cryosurgery uses a freezing probe to destroy redundant hemorrhoid tissue.
Once a popular technique it has fallen into disuse because of disappointing
results.
Operative treatment
o Excisional hemorrhoidectomy requires general or spinal anesthesia. It is
reserved for hemorrhoids either not suitable for office-based procedures or
where office-based procedure has failed. There are several variations to this
open technique and all are associated with a significant amount of
postoperative pain.
o Staple hemorrhoidopexy is a newer technique also done under general or
spinal anesthesia. In this procedure a circular strip of rectal mucosa above the
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hemorrhoids is excised and its edges stapled together with a circular stapling
instrument, thus elevating and restoring the vascular cushions back to their
original anatomical position. This procedure is associated with less pain than
that experienced after excisional hemorrhoidectomy.
Further readings
American Gastroenterological Association: Technical Review on the Diagnosis and
Treatment of Hemmorrhoids. Gastroenterology 2004;126:1463-73.