Haemorrhoids: What are they?
Haemorrhoids (or piles, which is their alternative name)
are vascular cushions (lined by blood vessels), which are very
common. It is quoted that over 50% of adults over the
age of 50 have haemorrhoids and experience symptoms
compatible with haemorrhoids. However, they can occur
at any age. They have a role in the maintenance of continence
(the prevention of accidents from the back passage and the
inappropriate passage of wind, liquid or solid stools).
What causes them?
Prolonged straining when going to the toilet, often associated with constipation and sitting on the
toilet for long periods of time are thought to be associated with the development of haemorrhoids.
The theory is that the perineal muscles (pelvic floor) remain unsupported during protracted straining
on the loo.
How do they present?
There are a wide variety of symptoms, but namely, bleeding and discomfort from the back passage,
both of which may be associated with other benign conditions (such as anal fissure),
itching (pruritus ani) or a small lump at the anal verge. If bleeding is identified then it is imperative,
that other sinister conditions should be excluded through
colonoscopy (telescope test of the back passage) or a CT pneumocolon (in the appropriate age group).
Management
In the majority of cases, haemorrhoids can be managed entirely conservatively
(i.e. do nothing and adopt a watch and wait policy). The most important aspect, is to exclude an
alternative cause for the symptoms, especially in the presence of rectal bleeding or other symptoms
such as ongoing constipation or diarrhoea. The conservative options available in the
outpatient setting include dietary advice (eating a diet high in natural fibre),
injecting haemorrhoids (injection sclerotherapy) or alternatively haemorrhoidal banding.
The latter are associated with very low risks e.g. recurrent bleeding or post procedure discomfort,
more so with banding.
Surgery
For patients with refractory symptoms, i.e. persistent symptoms that have not been improved by
the conservative measures described and where symptoms affect quality of life, the options
available are either conventional haemorrhoidectomy, which in the past has had bad press,
in view of the perceived complications, namely post operative pain. However, this is less so now.
Techniques such as stapled haemorrhoidectomy have been practised for over 10 years and is
particularly good for symptoms of haemorrhoidal prolapse. More recently,
the haemorrhoidal artery ligation technique (HALO) has been increasingly used as a technique with
encouraging results and less post operative discomfort.
The complications associated with surgery are low, but include post operative pain, recurrent bleeding
and to a lesser degree narrowing of the anus (stenosis).
Summary
Haemorrhoids are extremely common. The most important concept regarding their management
is to exclude alternative pathology, especially in the presence of rectal bleeding, through ideally
colonoscopy. This is to exclude any sinister lesion which can masquerade with identical symptoms.
The large majority of patients can be managed entirely conservatively, without recourse to surgery.
However, should symptoms prove to be problematic and impact on life style, then surgery is the
best long term option, assuming that the other conservative options described have been exhausted
prior to this.
Mr Romi Navaratnam MSc MS FRCS (Lon) FRCS (Gen)
Consultant Colorectal & Laparoscopic Surgeon/Hon. Senior Lecturer in Surgery
Secretary: 020 7078 3832 Fax: 0207 078 3898
Appointments 020 8887 2241 North Middlesex University Hospital
Royal Free & UCL Medical School
Appointments 020 7806 4060 Hospital of St John & St Elizabeth
020 7483 5181 Wellington Hospital (Central)
Correspondence: Hospital of St John & St Elizabeth 60 Grove End Road London NW8 9NH
05 May 2011
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