Haemorrhoids

What are haemorrhoids?

Haemorrhoids, also called ‘piles’, are enlarged and engorged blood vessels in the anal cushions of the upper portion of the anal canal.  The anal cushions normally serve an important role in the maintenance of continence and we are not normally aware they are there.  However, when they become enlarged they may exhibit symptoms, and in this case they are known as haemorrhoids.

Symptoms of haemorrhoids

Haemorrhoids can give mild intermittent symptoms, or the problems can be more persistent and severe.  Symptoms include rectal bleeding, perianal discomfort, anal seepage, pruritis (anal itch) and the sensation of something coming out of the bottom.

Grading of haemorrhoids

Haemorrhoids are classified into 4 grades:
• Grade I haemorrhoids are also known as internal piles; they do not prolapse (push out) out of the anal canal.  They usually bleed as the patient goes to the toilet; typically, the blood is fresh and red and seen to be separate from the stools, usually on the paper.
• Grade II haemorrhoids are larger, and sometimes prolapse from the anus during defaecation; however, the piles return inside once the patient stops defaecating.
• Grade III haemorrhoids prolapse from the anus during defaecation and the patient is able to push them back inside using a finger.
• Grade IV haemorrhoids can permanently protrude from the anus and cannot be pushed back inside.

Treatments

The most appropriate treatment option is usually determined by the severity and anatomy of the haemorrhoids.  This is something that your surgeon will advise you on.  Irrespective of the treatment offered, adopting a bowel friendly diet, which results in the passage of soft, formed stools without the need to strain, is advised.

Outpatient based treatments

Rubber band ligation

The application of rubber bands to piles is an effective, simple treatment for Grade I and II haemorrhoids.  A special device, inserted into the anal canal, delivers a small, tight rubber band onto the base of the haemorrhoid.  This stops the blood flow into the pinched-off portion of the haemorrhoid, which comes off during bowel motions in about a week.  Often, there is the need for more than one procedure to completely resolve a patient's condition.

Injection sclerotherapy

Injection sclerotherapy is another outpatient-based treatment for internal haemorrhoids.  An irritant chemical is injected painlessly by the surgeon to the base of the haemorrhoid.  This sets up an inflammatory reaction that leads to the formation of scar tissue that obliterates the haemorrhoid.  The patient will usually notice an improvement in the haemorrhoidal symptoms after 7-10 days.  The duration of the effect is variable; symptoms may recur after a year or so.

Surgery

Conventional haemorrhoidectomy

Also known as the Milligan-Morgan haemorrhoidectomy, this technique is still considered the ‘gold standard’ by which most other surgical haemorrhoidectomy techniques are compared.  Three tear drop-shaped incisions are created and the haemorrhoids lifted away from the lining of the anal canal.  The surgical wounds are either left open, separated by bridges of skin and mucosa, or stitched with a dissolvable suture.  The surgeon may place an absorbent pack into your rectum to help stem any further bleeding.  This usually stays in place until your first bowel movement.  The operation usually takes 30 to 60 minutes.  A Milligan-Morgan haemorrhoidectomy is thought to provide the most durable results; however, it is known as quite a painful procedure.  Much effort has been spent in trying to make the operation more comfortable and it can now be undertaken as a day case in many instances.

Stapled haemorrhoidectomy

This is a fairly new technique in which a circular stapler is placed inside the anal canal and lower rectum that removes a ring of the rectal tissue above the haemorrhoids.  This blocks the blood supply to the haemorrhoids so that they shrink.  It also has a physical effect to pull the piles back into the anal canal (also known as a haemorrhoidopexy).  The procedure is usually performed under a general anaesthetic and patients usually go home on the same day.

The procedure has been shown in studies to be safe and effective.  It appears to have fewer post-operative problems, such as pain and bleeding, than the Milligan-Morgan technique, although the long-term recurrence rate might be slightly higher.  It is endorsed by The National Institute for Health and Clinical Excellence (NICE).  There are, as with any operation, risks that your surgeon will discuss with you.

What are the risks of haemorrhoidectomy?

Haemorrhoidectomy is a commonly performed and generally safe surgical procedure.  However, all surgery carries an element of risk.  Specific complications of a haemorrhoidectomy are unusual but can include:
• Pain that can last for a number of weeks, although it usually eases off during that time
• Constipation for a few days after the operation – this can usually be treated through dietary measures and laxatives
• An infection of the operation site or the urinary tract
• Scar tissue causing the anus to become tighter (stenosis), which can make it difficult to pass stools – you may need treatment called anal dilation
• Bleeding, either immediately after the operation, or that starts a week or more after the operation, which may require further surgery
The chance of complications depends on the exact type of operation you are having and other factors such as your general health.  Your surgeon will explain how any risks apply to you.

Transanal haemorrhoidal dearterialisation (THD)

THD is an alternative, recently introduced technique.  A Doppler probe is used to identify the site of the haemorrhoidal artery within the anal canal, allowing the surgeon to accurately place a stitch to “tie-off” the artery.  Normally, this is necessary at six sites around the anal canal.  Further stitches are then placed to pull the haemorrhoidal tissue back up inside the anal canal.  Published results are very encouraging for this technique, and it has the perceived advantages of being less painful and not involving the removal of tissue.

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