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.
WHAT CAUSES HAEMORRHOIDS?
Haemorrhoids can develop from increased pressure in the lower rectum due to:
- Straining during bowel movements
- Sitting for long periods of time on the toilet
- Chronic diarrhoea or constipation
- Anal intercourse
- Low-fibre diet.
Digital examination. During a digital rectal exam, your doctor inserts a gloved, lubricated finger into your rectum. The exam can suggest to your doctor whether further testing is needed.
Visual inspection. Because internal haemorrhoids are often too soft to be felt during a rectal exam, your doctor may also examine the lower portion of your colon and rectum with a proctoscope or sigmoidoscope
GRADING OF HAEMORRHOIDS
Haemorrhoids are classified into four 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.
A number of other conditions give symptoms similar to haemorrhoids. These include:
ANAL ABSCESS & FISTULA
Anal abscess is a relatively common condition that most often occurs as the result of infection of an anal gland. Perianal abscess is an emergency and should always be drained in a timely fashion. Delayed or inadequate treatment may occasionally cause extensive or life-threatening tissue necrosis and septicaemia.
Anal fistula is an abnormal connection between the anal canal and the skin around the anus. Anal fistula can be classified depending on where the fistula runs in relation to the anal sphincter muscles. Occasionally anal fistula may be related to Crohn’s disease or, very uncommonly, anorectal cancer.
SYMPTOMS OF ANAL ABSCESS AND FISTULA
An anal abscess usually presents with symptoms of pain and swelling. A fistula often presents with recurrent discharge, bleeding, swelling, itching, or repeat episodes of abscess formation.
DIAGNOSIS OF ANAL FISTULA
Physical examination may reveal the external opening of the anal fistula. It is critical to establish the course of the fistula tract prior to therapy; this can usually be done through an examination under anaesthetic. Sometimes, magnetic resonance imaging (MRI) is used to map the extent of the fistula.
TREATMENT OF ANAL FISTULA
The goal of surgery is to eliminate the sepsis whilst maintaining continence. Simple fistulas that do not involve too much of the sphincter muscle can be treated by a lay open or fistulotomy procedure (surgical opening of the fistula tract). Fistulas that involve a significant proportion of the sphincter muscles are more safely treated by initial placement of a seton. A seton is a fine thread [usually of thin, coloured rubber] that allows drainage of sepsis. A subsequent procedure would then be necessary to definitively treat the fistula.
WHAT IS AN ANAL FISSURE?
An anal fissure is a split in the lining of the anal canal. Patients experience pain that occurs on defecation with passage of bright red blood, seen on the toilet paper. Defecation can be so painful that patients are afraid to go to the toilet; this then leads to the passage of large, hard stools that make the problem worse. A throbbing anal discomfort can persist for several hours after a bowel movement, caused by spasm of the anal sphincter. Healing of the fissure is often impaired by this spasm, which causes a reduction in blood supply to the anal canal lining.
TREATMENT OF ANAL FISSURE
Treatment is aimed at breaking the cycle of pain, spasm, and reduced blood supply. It consists of two components: achieving a soft stool consistency and relaxation of the internal sphincter. Medical therapy leads to healing in the vast majority of patients with acute anal fissures, and almost half of the patients with chronic fissures.
1. ACHIEVING A SOFT NON-IRRITANT STOOL
Dietary modification to increase the amount of fibre [aim for 25g to 30g per day], or taking a fibre supplement, can help achieve a soft stool consistency. It is also important to avoid foodstuffs that cause irritant faeces such as coffee, tea, caffeinated fizzy drinks, beer, chocolate, spicy foods, and tomatoes. The key, though, is to ensure that the patient increases the amount of water he or she drinks to 2 litres per day in the average adult.
2. RELAXATION OF THE INTERNAL SPHINCTER
Warm baths may ease the acute pain in the anal area. After a bath, the anal area should be carefully dried with a towel or a hair dryer with cool air. If a bath is not possible, using a wet baby wipe after a bowel motion is helpful to achieve optimal cleansing of the anal skin. Based on the theory that anal fissures fail to heal due to reduced blood supply, topical ointments that reduce the anal sphincter pressure such as diltiazem or GTN may be useful. Injection of a muscle relaxant [Botox] to the internal sphincter can be used as a second line therapy; studies show rates of healing of 60%-70% after a single injection of 15 or 20 Units of the relaxant. Surgical treatment is generally reserved for fissures that have failed to be treated successfully with medical therapy. Lateral sphincterotomy is the procedure of choice for the majority of surgeons. This operation surgically divides a portion of the internal anal sphincter and is highly effective in reducing symptoms of chronic anal fissure. However, persistent minor incontinence may occur in up to 35% of patients after the procedure; some will resolve within 6 weeks or so and some will be permanent.
ANAL SKIN TAGS
Anal skin tags are excess pieces of skin at the external opening of the anal canal. They often occur as a result of another anal condition, such as haemorrhoids or an anal fissure. They commonly cause no problem to the patient, but can lead to symptoms related to difficulty keeping the perianal area clean, namely pruritis (anal itch) and soreness. They can also bleed and catch on clothes.
Surgical treatment to remove perianal skin tags is usually performed as a day case, either under local or general anaesthetic. Prior to considering surgery, your specialist will ensure there is no other more serious underlying cause. Once skin tags are removed, the wound is either left open to heal over the course of a few weeks, or closed with sutures. It is important post-operatively to maintain a soft bowel consistency to decrease local irritation.
Malignant tumours of the anal canal are rare; the majority are squamous cell carcinomas, but other even rarer types are recognised, such as malignant melanoma, adenocarcinoma (cancer that originates in glandular tissue), carcinoid or lymphoma.
Squamous cell carcinoma of the anus accounts for only 1.5% of gastrointestinal tract cancers in the western world; however incidence appears to be rising. Risk factors include a history of infection with human papilloma virus (HPV), previous genital wart infection, HIV infection, cigarette smoking, and immunosuppression following organ transplantation.
Most anal cancers (70–80%) are initially diagnosed as benign anorectal conditions due to the non-specific symptoms they present with. These include pruritis (itching), pain, bleeding, and discharge.
Anal cancer is usually treated by chemotherapy in combination with radiotherapy. Surgery is reserved for treatment-resistant or recurrent disease.
VISIT OUR SISTER FACILITY, THE BIRMINGHAM COLORECTAL CLINIC, FOR MORE INFORMATION ABOUT THESE, AND OTHER CONDITIONS.
At the Birmingham Colorectal Clinic our team of highly trained Consultant Surgeons are there to provide top quality surgical care, personalised to your condition. Offering general surgery and colorectal expertise, you can rest assured that your assessment and treatment will be carried out by specialists.