What causes haemorrhoids and what can be done

Most of us would probably prefer not to talk about problematic piles or haemorrhoids, but they are very common and affect 50% of Irish adults at some point in their lives.

What causes them and what can one do to avoid them? Also what can be done, surgically and otherwise, if piles have become a real pain in the butt?

First things first, what’s the correct name – piles or haemorrhoids?

“Haemorrhoids is the medical term,” Dr Hannon says. “Piles is a colloquial term, like a hernia being described as a rupture, for example.”

Haemorrhoids are often thought to be varicose veins of the back passage, but is this correct?

“That’s not completely accurate. Haemorrhoids are swollen and congested veins around the back passage, but it wouldn’t be accurate to call them varicose veins,” says Dr Hannon. “Varicose veins occur because of defective valves in the veins of the legs.”

Haemorrhoids are an anatomical feature of the anal canal, he says. They are designed to be there.

“They perform an important function. They’re there to create a seal so that you don’t get leakage of mucous or faecal material on to the skin around the anal canal.”

There are three haemorrhoidal, vascular “cushions” sitting around the top of the anal canal, he adds.

“Over time, the blood vessels may become congested and engorged and the haemorrhoidal cushions become enlarged. This enlarged tissue, when it occurs, can then drift down the anal canal.

“This is more likely to happen if the person is prone to constipation and straining or is obese or pregnant, as these are conditions that put pressure on the pelvis and cause swelling of the tissues.

“That swelling of the haemorrhoidal tissue then breaks the seal of the anal canal and mucous leaks onto the skin around the anal canal. This leads to the symptoms of haemorrhoids – bleeding, itchiness, irritation, and discomfort.”

Grades one to four G

Generally speaking, haemorrhoids are categorised according to their position in the anal canal, he says.

“Haemorrhoids that stay up above the anal canal are called grade one haemorrhoids, those that come down a bit but go back up by themselves are grade two. Haemorrhoids that prolapse down and either have to be put manually back up or are down all the time are categorised as grade three or four. They all give different symptoms depending on the grade.”

Table one lists the symptoms of each grade.

Seeing a surgeon

At what point does a person get referred to a surgeon when they have this condition?

“Many patients come to me because of rectal bleeding, fearful that it was something more sinister, like bowel cancer.

“A colonoscopy is done, in the first instance, to investigate exactly what’s wrong. Afterwards, if the patient is reassured that the cause of the bleeding is haemorrhoids and not anything more sinister, he or she may not be concerned about the bleeding and may decide not to have any treatment.”

Treatment

“The first line of treatment for haemorrhoids though, after appropriate investigation, regardless of their grade, is lifestyle modification,” he says.

“If the person is overweight, they should lose some weight so that their obesity no longer puts pressure on this area.

“I always ask patients about their diet and advise adopting a high fibre diet and drinking more fluids throughout the day,” he says. “There is evidence that people who have regular meals, particularly breakfast, are less likely to experience troublesome haemorrhoids.”

Breakfast time is usually a point where you take in fibre –porridge, bran or Weetabix, for example – so if you’re omitting this meal then you may not be getting enough fibre or roughage in your diet.”

Up to 50%-60% of patients with symptomatic haemorrhoids will get better without any intervention other than lifestyle advice, he adds.

“Usually by the time patients are referred to me they have tried lifestyle modification but are still symptomatic with bleeding or persistent discomfort and itch.”

Types of surgical treatment

If lifestyle modification doesn’t work and the person is still experiencing bleeding or persistent discomfort and itch, surgical treatment is available.

There are three initial procedures to choose from, Dr Hannon says, for grade one or two haemorrhoids. These are:

All involve treatment as a day procedure.

“All three are designed to create some scarring above the haemorrhoid. The rationale is roughly the same for all three treatments. The treatments disrupt the blood supply to the haemorrhoid, make it less bulky (shrivel it up) and create a small scar under the lining of the rectum. The scarring is a way of pulling the haemorrhoids back up into the anal canal. Rubber band ligation is the most effective of these treatments and is the treatment that I offer patients with grade one or two haemorrhoids initially.”

For many years, there was no treatment available for grade three and four haemorrhoids other than open haemorrhoidectomy, he says.

“In this procedure, we remove the skin and mucosa in the three areas (the three vascular cushions around the anal canal). It’s typically a very painful procedure and not well tolerated by patients. As surgeons, we have been trying to develop alternative procedures that are more effective than, say, rubber band ligation but better tolerated than open haemorrhoidectomy. A significant development that has been available for the last few years is THD or transanal haemorrhoidal dearterialisation.

“With THD, a Doppler probe is inserted into the anal canal and this probe identifies and obliterates the relevant blood vessel. The haemorrhoid is then stitched or sutured back up into the anal canal. It deals with the haemorrhoidal artery and causes the haemorrhoid to become less bulky. It also deals with the mucosal prolapse which causes the symptoms.

“It ticks all the boxes of what we want a haemorrhoidal operation to do. You don’t have to cut any skin so the recovery time is quicker and it’s less uncomfortable for patients. It’s generally done as a day procedure under general anaesthetic.

“There may be a bit of discomfort for three to seven days afterwards but the discomfort is usually short-lived because there is no open wound – the surgery is all internal. I usually send patients home on some painkillers, stool softeners and antibiotics for a few days. No other treatment is neccessary.”

Because this procedure is well tolerated in patients, Dr Hannon has seldom done an open haemorrhoidectomy in the past six years as a consultant.

“I would tend to reserve open haemorrhoidectomy for patients with an acutely thrombosed haemorrhoid where there is little option for more conservative measures. In general, treatments for haemorrhoids have progressed substantially in the past five to 10 years.”

Useful websites

Dr Rob Hannon is a consultant in general, colorectal and laparoscopic surgery at the Beacon Hospital. www.beaconhosp.ie

www.ital.ie