Haemorrhoids are clusters of smooth muscles, vascular and connective tissues, which lie along your anal canal in 3 columns—left lateral, right anterior, and right posterior positions. Hemorrhoids are present universally in healthy individuals. Hemorrhoids aid in the process of bowel movement. Nonetheless, the term “haemorrhoid” is commonly invoked to characterize the pathologic process of symptomatic hemorrhoid disease instead of the normal anatomic structure. As the supporting tissue of your anal cushion weakens, downward displacement of the cushions can occur, causing venous dilation and prolapse.
What Causes Haemorrhoids?
Haemorrhoids do not occur due to a single causative factor, says the best laser surgeon in Kolkata. Most often, however, they are caused by an increased pressure on the anal canal. This can be due to:
- Chronic (ongoing) constipation
- Straining during bowel movements
- Pregnancy and childbirth
- Sitting too long on the toilet
- Strenuous exerciseor heavy lifting
Classification of a hemorrhoid
- External haemorrhoids, located below the dentate line, are covered with anoderm and consist of squamous epithelium. They are innervated by somatic nerves supplying the perianal skin and thus cause pain.
- Internal hemorrhoids, located just above the dentate line, are covered by columnar epithelium, innervated by visceral nerve fibers and thus cannot cause pain.
- Grade I haemorrhoids don’t project from your anus. They may cause bleeding, but otherwise cause relatively less symptoms.
- Grade II hemorrhoids are the ones that stick out from the anus during bowel movements. They go back to their initial position when straining stops.
- Grade III hemorrhoids stick out with straining or on their own. They do not get resolved by themselves, however, they can be pushed back into their initial position.
- Grade IV hemorrhoids are the ones that stick out, but cannot be reduced. These are extremely painful and require prompt treatment.
Symptoms and Presentation
Almost 40% of individuals with hemorrhoids are asymptomatic. For those who are symptomatic, there is great variance in the constellation of symptoms. For internal hemorrhoids, the following signs and symptoms are experienced:
- Bleeding: It is one of the most common symptoms that occur with defecation and is almost always painless.
- Pulling sensation in the pelvis: Prolapsed internal hemorrhoids are accompanied with mucus discharge, mild fecal incontinence, irritation of perianal skin, and sensation of perianal fullness.
- Pain associated with internal hemorrhoids is lesser than that with external hemorrhoids, but it can occur in the setting of prolapsed internal hemorrhoids that develop gangrenous changes due to the associated ischemia. In contrast, in external hemorrhoids, pain is most common due to activation of perianal nerves associated with thrombosis. People usually describe a painful perianal mass that is tender to palpation.
- Bleeding also occurs if ulceration forms due to necrosis of the thrombosed hemorrhoid
- Painless external growths on skin usually develop from previous edematous or thrombosed external hemorrhoids.
- Digital examination – It excludes distal rectal mass and anorectal fistula or abscess. Assessment of sphincter integrity during the examination process is important.
- Anoscopy-It involves rigid or flexible proctosigmoidoscopy.
- Colonoscopy – It is used for complete colonic evaluation.
Conservative Medical Treatments
Dietary and lifestyle modifications are one of the most important aspects of conservative treatment. Specifically, lifestyle modifications include greater intake of oral fluids, reduction in fat consumption, regularly exercising, and avoiding straining. Dietary recommendations include increase in fibre intake that lessens the shearing action of passing hard stool.
Nonsurgical Office-based Procedures
Rubber Band Ligation
It is typically performed in the office and is used for grade II and III internal hemorrhoids.
It is used for patients with grade I and II internal hemorrhoids and may be a good option for patients on anticoagulants.
It refers to the application of infrared light waves to the haemorrhoidal tissues and can be used for grade I and II internal hemorrhoids.
It is based on the concept that freezing the internal hemorrhoid at low temperatures results in tissue destruction.
For symptomatic Grade ΙΙΙ-ΙV hemorrhoids and hemorrhoids resistant to non-operative procedures, a surgical procedure can be adopted. It is required in only 5-10% of patients.
The best proctologist in Kolkata usually performs two major types of haemorrhoidectomy: Ferguson, or closed haemorrhoidectomy and Milligan–Morgan, or open haemorrhoidectomy
An alternative to operative haemorrhoidectomy, it is a stapled procedure in which a circular stapling device is used to resect and fixate the internal hemorrhoid tissues to the rectal wall. The technique is also known as ‘procedure for prolapse and hemorrhoids (PPH)’. This is comparatively less painful and allows quicker recovery.
Doppler-guided Hemorrhoidal Artery Ligation
It involves a Doppler transducer allowing sequential identification of the position and depth of superior rectal arterial branches, which are then selectively ligated 2-3 cm above the dentate line. The interference with the blood supply reduces bleeding and volume of the hemorrhoids and symptomatic relief is usually evident within 6-8 weeks.