Haemorrhoids and Its Management – A Short Review.

HAEMORRHOIDS AND ITS MANAGEMENT – A Short Review.
by
EBGERE ONYEKA BARNABAS, Rn, BnSc, Rpon in view.

Haemorrhoids are swellings containing enlarged blood vessels found inside or around the rectum and anus (Lawrence A. 2018).

Haemorrhoid is an abnormal mass of dilated and engorged blood vessels in swollen tissue that occurs internally in the anal canal or externally around the anus that may be marked by bleeding, pain or itching and that when it occurs internally often protrude through the outer sphincter of the anus and when occurring externally may lead to thrombosis.( Webster M .2018).

Haemorrhoid are defined as the symptomatic enlargement and distal displacement of the normal anal cushions (Lohsiriwat V. 2017)

Haemorrhoid are dilated (enlarged) veins in the walls of anus and sometimes around the rectum usually caused by untreated constipation but occasionally associated with chronic diarrhoea (Shiel W.C 2016).

They are vascular structures in the anal canal in their normal state. They are cushions that help with stool control. They become a disease when swollen or inflamed.

According to (David B, 2011), the exact cause of hemorrhoid remains unknown. A number of factors which increase the pressure of abdomen are believed to be involved thus:
Constipation, diarrhea and sitting on the toilet for a long time, Pregnancy – increased pressure in the hemorrhoid tissue due to pregnancy may initiate hemorrhoid or aggravate existing ones, Chronic cough, pelvic floor dysfunction, obesity, genetics, absence of valve within the hemorrhoid angina etc.

According to Chen and Herbert (2010) approximately 50% to 66% of people have problems with hemorrhoids at some point in their lives, males and females are both affected with about equal frequency. Haemorrhoids affect people most often between 45 and 65 years of age. It is more common among the wealthy and outcomes are usually good.

The first known mention of the disease is from a 1700BC Egyptian papyrus

The signs and symptoms of haemorrhoids depends on the type present. Internal haemorrhoid often result in painless, bright red rectal bleeding when defecating.

External haemorrhoids often result in pain and swelling in the area of the anus. If bleeding occurs it is usually darker, symptoms frequently get better after a few days (David B, 2011).

Hemorrhoid can be diagnosed using physical examination, digital rectal examination, anoscopy, sigmoidoscopy etc (Chen and Herbert 2010).

Treatment of haemorrhoids can often relieve the mild pain, swelling and inflammation. Haemorrhoids can also be managed with home treatments such as: eating high fiber foods, use topical treatments, soak regularly in a warm bath or sitz bath, keep the anal area clean, do not use dry toilet paper, apply cold and take oral pain relievers.

Complications from hemorrhoids are rare, but can include; blood clots, bleeding, iron deficiency anemia (Webster M .2018).

Surgical removal of hemorrhoids is known as haemorrhoidectomy.

Classification of Hemorrhoids
Hemorrhoid are classified into two types according to David B. (2011).
•Internal hemorrhoid.
•External hemorrhoid.
•Internal Hemorrhoid.

Those that appear above internal sphincter (they originate above the pectinate line) are called internal hemorrhoid. This type lies within the rectum. It usually present with painless, bright red rectal bleeding during or following a bowel movement. The blood typically cover the stool (hematochezia) is on the toilet paper or drip into the toilet bowl (Brunner and Suddarths, 2014).

The stool itself is usually normally coloured. Other symptoms include mucus discharge, a perineal mass if they prolapsed through the anus, itchness and fecal incontinence.
Internal hemorrhoids are usually only painful if they become thrombosed or necrotic, if not they are usually painless.

According to Chen, Herbert (2010) internal hemorrhoids were classified into four grades based on the degree of prolapse.
• Grade I: No prolapse, just prominent blood vessels.
Grade II: Prolapse upon bearing down, but spontaneous reduction.
Grade III: Prolapse upon bearing down, requiring manual reduction.
Grade IV: Prolapse with inability to be manually reduced.

External Hemorrhoid: This type of hemorrhoid lies outside the external sphincter (Brunner and Suddarth, 2014).
If not thrombosed external hemorrhoids may cause few problems. However, when thrombosed, hemorrhoid may be very painful. Nevertheless, this pain typically resolves in two to three days.
The swelling may however, take a few weeks to disappear. A skin tag may remain after healing if hemorrhoids are large and cause issues with hygiene, they may produce irritation of the surrounding skin and thus itchiness around the anus (Dayton, Peter and Lawrence, 2016).

Pathophysiology
Haemorrhoids are vascular structures in the anal canal (Chen& Herbert, 2010). In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term “hemorrhoid” is often used to refer to the disease (Chen, Herbert, 2010).
According to Brunner and Suddarth’s (2014), hemorrhoids are dilated portions of veins in the anal canal.
Hemorrhoids are very common; nearby three out of four adults (50 years of age) will have hemorrhoids from time to time (Brunner and Suddarths, 2014).
Male and female are both affected with about equal frequency (between 45 – 60 years age).
It is mor e common among the wealthy.
Approximately 50% to 66% of people have problems with hemorrhoids at some point in their life (Lorenzo Rivero, 2019).
According to David B (2011), the exact cause of hemorrhoid remain unknown. A number of factors which increase the pressure of abdomen are believed to be involved thus:
Constipation, diarrhea and sitting on the toilet for a long time.
Pregnancy – increased pressure in the hemorrhoid tissue due to pregnancy may initiate hemorrhoid or aggravate existing ones.
Chronic cough, pelvic floor dysfunction, obesity, genetics, absence of valve within the hemorrhoid angina etc.
The signs and symptoms of hemorrhoid defers on the type present.
Painless bleeding during bowel movements you might notice small amounts of bright red 1“1blood on your toilet or in the toilet.
Itching or irritation in your anal region.
Pain (external hemorrhoid) or discomfort.
Swelling around the anus.
A lump near the anus, which may be sensitive or painful (may be a thrombosed hemorrhoid, Brunner and Suddarths, 2014).

Hemorrhoid cushions are a part of normal human anatomy and become a pathological disease only when they experience abnormal changes. There are three main cushions present in the normal anal canal.

These are located classically at left lateral right anterior, and right posterior positions. They are composed of neither arteries nor veins, but blood vessels called sinusoids connective tissue and smooth muscle (Dayton et al, 2016).

Sinusoids do not have muscle tissue in their walls as veins do. This set of blood vessels is known as hemorrhoidal plexus. Hemorrhoid cushions are important for continence. They contribute to 15 – 20% of anal closure pressure at rest and protect the internal and external anal sphincter muscles during the passage of stool. When the person bears down, the intra abdominal pressure grows and hemorrhoid cushions increase in size, helping maintain anal closure. Hemorrhoid symptoms are believed to result when this vascular structure slide downwards or when venous pressure is excessively increased.

Increased internal and external anal sphincter pressure may also be involved in hemorrhoid symptoms. Two types of hemorrhoids may occur: internal from the superior hemorrhoidal plexus and externals from the inferior hemorrhoidal. The pectinate line divides the two regions (David B. 2014).

Investigations To Aid Diagnosis
Physical Examination: A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids.
Rectal Examination: A rectal examination may be performed to detect possible rectal tumors, polyps an enlarged prostate or abscesses.
Anoscopy: Visual confirmation of internal hemorrhoids may require anoscopy, insertion of a hallow tube device with a light attached at one end.
The two types of hemorrhoids are external and internal which are differentiated by their position with respect to the pectinate line. Some persons may concurrently have symptomatic versions of both. If pain is present, the condition is more likely to be an anal fissure or an external hemorrhoid rather than an internal hemorrhoid (Chen& Herbert, 2010).

Management
According to Dayton et al. (2016), management of hemorrhoid is divided: into

Conservative management

Surgical management
Conservative Management
Hemorrhoid symptom and discomfort: can be relieved by good personal hygiene and by avoiding excessive straining during defecation.
High fiber diet/fiber supplements: A high fiber diet or high residue diet that contains fruit and bran along with increased fluid intake may be necessary to enhance the passage of soft bulky stool and prevent straining.
Warm compresses, sitz bath, analgesic ointments and supporistories, astringents (e.g witch hazel) and bed rest reduce engorgement.
Use of barrier cream: such as petroleum jelly or Zinc oxide, an analgesic agent such as Lidocaine and a vasoconstrictor such as epinephrine (David B. 2011).
Pregnancy: Hemorrhoid occurs as a result of pregnancy pressure, usually result following pregnancy but if such fails active treatments is often delayed until after delivery.
Other conservative managements are:
Rubber and ligation: This is typically recommended as the first line treatment in those with grade 1 to 3 diseases. It is a procedure in which elastic bands are applied on to an internal hemorrhoid, at least 1cm above the pectinate line to cut off its blood supply within 5 – 7 days, the withered hemorrhoid falls off.
If the band is placed close to the pectinate line intense pain results immediately afterwards (Chen& Herbert, 2010).
Sclerotherapy: This involves the injection of a sclerosing agent such as phenol into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids shrivel up (Chen& Herbert, 2010).

Surgical Management
The surgical removal of varicosities of veins or prolapsed mucosa of the anus and rectum that do not respond to conservative treatment is called hemorrhoidectomy (Philips, 2017).
Hemorrhoidectomy can be done as a day case especially if it is a stapled hemorrhoidectomy which is usually less painful and associated with faster healing compared to complete removal of hemorrhoid. In such case, the patient may be booked as a day case. In severe case of hemorrhoid which excisional hemorrhoidectomy can be applied, the patient will be admitted to the ward a day before the surgery.
Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily in severe cases. It is associated with pain and usually requires 2 – 4 weeks for recovery. However, the long term benefit is greater in those with grade 3 hemorrhoids as compared to rubber band ligation. It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24 – 72 hours. Glyceryl trinitrate ointment after the procedure helps both with pain and healing (Lorenzo, 2019).
Doppler – guided, transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound Doppler to accurately locate the arterial blood flow. These arteries are then tied off and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate but fewer complications compared to a hemorrhoidectomy.

Cauterization Methods: A number of cauterization methods have been shown to be effective for hemorrhoids, but are usually only used when other methods fail. This procedure can be done using electrocautery, infrared radiation, laser surgery or cryosurgery.
Infrared cauterization may be an option for grade 1 or 2 diseases in those with grade 3 or 4 diseases, reoccurrence rates are high.
Stapled hemorrhoidectomy, also known as stapled hemorrhoidoplexy, involves the removal of much of the abnormally enlarged hemorrhoidal tissue followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomical position. It is generally loss painful and is associated with faster healing compared to complete removal of hemorrhoids. However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorrhoidectomy. So it is typically only recommended for grade 2 or 3 disease (Dayton et al, 2016).

Preventions of Hemorrhoid
According to Chen &Herbert,(2010) haemorrhoids can be prevented through the following measures:
Avoiding excessive straining during defecation, avoid constipation and diarrhoeaea, either by eating a high fiber diet and increase a fluid intake or by taking fiber supplement.
Sufficient exercise
Spending less time attending to defecate, avoiding reading while on the toilet
Avoid lifting of heavy object
Weight control or losing weight for overweight person

Complications of Hemorrhoids
Anal fistula or tissue
Constipation
Excessive bleeding
Excessive discharge of fluid from the rectum
Inability to urinate or have a bowel movement
Severe pain, especially when having a bowel movement (David B.2014)


REFERENCES
Brunner & Suddarth (2014). A text book of Medical surgical nursing; 12th edition; Baltime publisher, New York.

Chen & Herbert (2010). Text Book on Medical Surgical Nursing 15th Ed. J. B. L. Princott Company Philadelphia USA.

David B.(2011). Definition of hemorrhoid retrived December 2, 2019 from http://www.davidb .

Lohsiriwat V.(2017).Hemorrhoid Definition retrived May 7, 2017 from http://www.ncbi.nlm.nih.gov.pmc

Lorenzo R. (2019) Hemorrhoids. Mosby’s Dictionary of Medicine, nursing & health
professions. 9th edition. St Louis ml; Elsevier Mosby.

Shield W.C (2016) Hemorrhoid Definition Retrieved January 24, 2016 from http://www.medicinenet.com

Waugh A. & Graunt A.(2015), Anatomy and physiology in health and illness.12th edition; USA. Churchill livingstone.

Webster M. (2018) M. W. Definining Hemorrhoid retrieved October 7, 2018 from http://www.merriam-webster


About the author.