What are Haemorrhoids?
Haemorrhoids are enlarged cushions around the back passage. These cushions are made up a complex of small arteries and veins which are important in preventing leakage from the anus.
Anatomically there are three cushions lying in the left lateral, right posterior and right anterior positions and can be shrunk by applying an elastic band 2 to 3 centimetres above the dentate line in the anus where there are no pain nerves. It is important to restore the cushions to normal size but not to remove them completely.
The cause of haemorrhoids is anything that increases intra-abdominal pressure over time such as constipation or diarrhea or obesity or heavy lifting.
Pregnancy is a good example of a short period of increased pressure, relieved when the baby is delivered and this type of haemorrhoid may not require any major treatment.
Lack of soluble fibre (e.g. bran), insufficient water, straining and sitting for a long time on the toilet are major factors in causing haemorrhoids and fissures and their complications.
It is important to recognize that airline travel and pressurized aircraft can give problems with upset bowels and haemorrhoid exacerbations. The best advice is to pack a whole-wheat sandwich to eat, avoid food and alcohol on the plane, drink as much water as you can from the service and supplement this with two litres of water you take on board the plane. Try to walk about as much as you can on the flight.
Haemorrhoids get larger with time and may bleed or itch at the beginning but later come out transiently or even stay out all the time.
Skin tags can form on the outside and sometimes the haemorrhoids can thrombose and become very painful. When there are large tags it may be difficult to keep the area clean and there may be a discharge and itch or irritation.
After the age of 50 years 50% of people will have haemorrhoids but only 1% will need treatment each year. 97% are treated with banding.
Methods of Treatment
The best treatment is prevention by taking enough dietary fibre (2 tablespoons of bran, Metamucil or Benefibre, ground flax, ground chia seeds or inulin-chicory root) and 7 to 8 glasses of water per day and not being overweight and taking some exercise. With the development of early haemorrhoids this is usually still the best way to manage the problem and the addition of a cream (no difference between most of the emollient creams, so go cheap) is usually sufficient. The use of a steroid cream or analgesic ointment should generally not be used for longer than a week. An important change that will help is not spending longer than 2 minutes on the toilet to have a bowel movement, and going back a few hours later if you cannot have a bowel movement then.
If this does not work, you will likely be sent to a specialist who will, first of all, make sure that haemorrhoids are the only problem. Other causes such as inflammatory bowel disease, fissure or even bowel cancer will need to be ruled out if there is a family history of cancer, weight loss, blood mixed in with the stool or a lot of pain.
Usually you will have a digital rectal exam and proctoscopy but a sigmoidoscopy or colonoscopy may be needed depending on the risk factors. Although Laser, injection of sclerosant, or infrared are used for a few patients, the vast majority of haemorrhoids are treated by rubber band ligation since the 1960's. A few patients with very advanced haemorrhoids (grade 4) may require surgery because of the large amount of haemorrhoid protruding through the anus, but it is still often worth trying ligation because it is so much better accepted by the patient, and the external lump(s) may shrink by as much as 80%.
Because of the issues related to sterilization of instruments between cases and the risk of cross infection there is a need for a disposable ligator. The advent of HIV, the recognition of the highly infectious Hepatitis B and C have made patients and health professionals switch to disposables whenever feasible for other procedures. The advent of the Medsurge proctoscope and bander (Reagan) makes this possible now for haemorrhoids.
The patient is informed of the steps in the procedure, and placed on a couch on the left side with only the anal area exposed. The surgeon is gloved.
He performs a digital exam and then directs the lubricated proctoscope into the anus pointing it towards the umbilicus first and then after three centimeters, backwards and inserts the proctoscope fully and then removes the obturator. With the aid of a bright wall or floor lamp the three haemorrhoidal masses are identified and the internal foramen turned towards each in turn starting with the left, then the right anterior then the right posterior. If this is at the right point (1 to 2 cms above the dentate line) the patient will have no pain and the barrel of the syringe can be locked and the band fired onto the pedicle. The ligator is left for some time to suck in tissue. Otherwise, if there is discomfort, the vacuum is released and the tip of the syringe applied higher up.
Usually only one band is performed at each visit as it has been shown that multiple ligations have more complications.
The technique of sucking the right part of the haemorrhoid and locking the syringe requires some practice, and can be done with one hand without repositioning the fingers or with one hand locking the barrel with the thumb and repositioning the fingers for the final locking movement. There is a feeling of fullness and slight discomfort but pain is rare. If pain occurs it comes on immediately and can be quickly relieved on the spot by moving the band a little with a gloved finger. The haemorrhoids can be done one at a time and repeated in the order noted at weekly intervals until all three are done.
Following the procedure the patient should take a high fibre diet and 7 to 8 glasses of water to avoid constipation. Painkillers are not required. The patient may feel a fullness of the rectal area for up to 24 hours.
Complications are extremely rare (less than 0.3% of procedures) and include bleeding, dicomfort and swelling. The more serious side effects of difficulty in passing urine and - more rarely still – bacteraemia have not been seen so far in 20,000 procedures.
The patient should be seen and re-examined in three or four weeks.
Iain G.M. Cleator FRCSC,FRCSE,FRCS,FACS Professor of Surgery UBC
Commonly Asked Questions
If I have a lot of pain from haemorrhoids or fissure what should I do?
A: Haemorrhoids are painful if they stick out and the blood in them becomes clotted (thrombosed). Lying flat or having a warm bath with a tablespoon of salt in the water is helpful.
Do not take painkillers with codeine in them as these cause constipation and makes things worse. Fissure pain responds to the same routine and is much the commoner source of pain.
If I get bleeding from Haemorrhoids, what should I do?
A: You should lie flat with your bottom a little higher than your head. The reason for this is that the bleeding is usually form the veins and walking, sitting on the toilet etc just increases the pressure and makes the bleeding worse. An ice pack applied to the anal area also helps.
If the bleeding is more than a pint contact your doctor or go to the nearest emergency. Remember that blood loss looks more than it is when it is in the toilet.
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Your patience, concern and meticulousness touch the heart and respect of a patient like me.
I appreciate your time and care.
Wish you all the best!
I feel so much better you have no idea.
I am much better and the bleeding has stopped (after first appointment).
I should have come 10 years ago.
It’s perfect! I can’t believe it!
I feel great for the first time in my life.
It was a miracle. I felt good the next day.
The next day there was relief – not complete of course.
I wasn’t aware this was available.
Phenomenal! 110% better!
They are not bleeding any more and it was not painful and they are not sticking out now. This is cool.
Great! Haven’t felt this good in 2 years.
I was very afraid at the beginning when I saw the blood.
It worked very good.
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Having a comfy bum makes all the difference in the world.
After suffering fifty years of foolish discomfort and only three visits to your office I feel like a new woman. Thank you for making such an amazing difference in my everyday life.
Best thing I ever did was coming to see you - wish I'd done it sooner.
I had no idea it would be so straightforward.
I was a bit surprised - I felt nothing! When I had banding in 1999 it was painful.
I am exceedingly grateful for the relief you provided to my pain and discomfort with the presence of your added touch of warm compassion. Thank you so much for the skill and proficiency you displayed in dealing with my physical condition.
I feel a million times better