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Haemorrhoids: prevention and treatment

Paula Studd
BSc(Hons) RGN
Consultant Nurse Coloproctology
St Mary's Hospital
London

Haemorrhoids, commonly known as piles, are very common in the Western world and can occur at any age and affect both sexes equally. The exact incidence is unknown but is thought to be in the region of 10-25% of the adult population.(1)
Anal cushions are normal anatomy within the submucosa of the anal canal present from infancy. They act as a compression-type lining that allows the anus to close completely to aid complete continence. Most people have three of these cushions, which typically appear in the left lateral, right anterior and right posterior positions - that is, at the 3, 7 and 11 o'clock positions (see Figure 1).

[[NIP25_fig1_50]]

Haemorrhoids occur when the anal cushions become displaced, a mechanism proposed as the theory of sliding anal canal.(2) They have a rich blood supply that can easily become engorged with blood if pressure is increased in and around them as a result of straining to defecate or being constipated. This tissue can then easily be traumatised by the swelling and tautness of the cushions, causing bright red rectal bleeding.
Haemorrhoids can be internal or external to the anal canal. Internal ones are covered with columnar epithelium, and external ones by squamous cell epithelium. The demarcation between the two epithelial types is called the dentate (or pectinate) line where the innervation changes. Below the dentate line there is high sensitivity and hence pain, especially when haemorrhoids become thrombosed, but with no sensory nerves above the dentate line internal haemorrhoids can be painless.
Haemorrhoids can be classified by the degree of prolapse and their reducibility, but this does not reflect the severity of the symptoms (see Table 1).

[[NIP25_table1_52]]

Presentation and symptoms
Bright-red rectal bleeding is the most common presenting symptom with haemorrhoids. This blood is separate to the stool and generally occurs only after a bowel movement. These symptoms often arise from enlarged internal haemorrhoids rather than the external type.
The volume of blood from haemorrhoids can vary and may either be dripping into the toilet pan or just seen on the toilet paper when wiping. The amount of blood can be alarming, which can cause understandable concern.
If the haemorrhoid prolapses with a bowel movement it can be associated with an uncomfortable sensation of fullness, incomplete evacuation and a dull ache sensation.
Faecal soiling can occur in third- and fourth-degree piles as a result of the anal muscles stretching and causing impaired continence. Mucus discharge and pruritis ani (itching) can also occur, causing perianal hygiene to be difficult to maintain.
Anal skin tags are permanent residual effects of having had haemorrhoids, and can cause problems in maintaining cleanliness and irritation. People should be advised about good perianal hygiene after each bowel movement by advising the use of nonalcohol soap or moist nonalcohol wipes, dabbing dry with soft towel, wearing loose cotton underwear and avoiding talcum powder. They can be removed surgically if there are troublesome daily symptoms, but the procedure does require a general anaesthetic so this is not undertaken lightly, and the risks and benefits should be explained to the patient before going ahead.

Causes
The pathogenesis of haemorrhoids is unknown. Many clinicians believe that factors such as inadequate fibre in the diet, prolonged sitting on the toilet and ongoing straining down to open bowels can contribute to haemorrhoids developing.
The most commonly regarded cause amongst clinicians is processed food and a diet low in fibre. A lack of fibre will produce smaller, harder stools that result in patients having to strain to pass the stool. Also, it is thought that ageing causes weakening of the support structures, which facilitates prolapsed haemorrhoids.
Other factors may include constipation, diarrhoea, pregnancy/labour and a familial tendency. It may be simply that there has been a change in the diet or work patterns, or, more awkward to ascertain, that of anal trauma, possibly through anal intercourse. However, none of the above factors has actually been rigorously proven.
Haemorrhoids can also be seen in patients with spinal cord injury,(5) in men with dysuria because of prostate problems, and also in those with ascites, pelvic tumours and raised portal venous pressure with hepatic cirrhosis.(6)

Assessment and investigation
While assessing patients with rectal bleeding one must never assume that the cause is haemorrhoids. Symptoms and the presence of haemorrhoids can mask colorectal malignancy and other more serious bowel pathology.
It is essential to ascertain from the patient what their current symptoms are. The key is to establish whether there has been a change in the way their bowel functions as well as finding out more about the blood loss.
The presence, quantity and frequency of bleeding is important and whether that bleeding is bright or dark red, and mixed or separate to the stool.
It is also important to ask whether there is anal pain associated with a palpable lump, which is then likely to be either a thrombosed haemorrhoid or an anal fissure with a sentinel pile/tag. As many as 20% of patients with haemorrhoids have concomitant anal fissures.(6)
Questions should also be asked about any family history of bowel disease, general health, previous illnesses and operations, allergies (the phenol injection for haemorrhoids is in almond oil) and sexual habits, for example anal intercourse. This can be done as a self-assessment sheet for the patient to complete and bring to clinic.

Examination
All patients who report rectal bleeding should at least have a rigid sigmoidoscopy. In some centres flexible sigmoidoscopy is done as a routine for all rectal bleeding patients. Current practice guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) advocate a minimum of anoscopy and flexible sigmoidoscopy for bright-red rectal bleeding.(7)
To carry out an examination in the clinic the patient needs to be in the left lateral position so that inspection of the perianal area (by gently spreading the buttocks in both directions horizontally and vertically) can be observed for the presence of any skin tags, fissures, fistulae, polyps or cancers. Sometimes it may be difficult to see anal pathology, so asking the patient to bear down into their bottom can reveal a fissure or prolapsed haemorrhoids.
With such an intimate part of the body it is important to acknowledge the patient's privacy and dignity, ensuring they are covered, using sensitivity and ensuring they know what you're doing before you do it - even the cold jelly can give them a shock if they don't know it's about to happen.
Per-rectal examination (PR) is done by using the pulp of a finger placed over the anus then gently curled in and then swept around the total circumference of 360˚ to feel the mucosal lining, which should be smooth, identifying any irregularities, strictures or masses.
During a PR examination the prostate gland in men and uterine cervix in a female may be felt. A firmness felt anteriorly in females may be a tampon, so check with the patient. The examining finger should be inspected on removal for blood, mucus, pus or dark stool and noted.
A rigid sigmoidoscopy and proctoscopy/anoscopy is important for directly visualising the lining as long as the rectum is clear of stool. Some hospitals will ensure that patients have used a stimulant suppository before they come to clinic.
Bleeding not typical of haemorrhoids, such as dark red, or mixed in the stool, will need further investigation. A positive faecal occult blood test (FOBT) indicates hidden blood within the stool, darker-coloured stools or anaemia. Any change in bowel habit or unexplained weight loss should also be established.
The Department of Health has written guidelines for primary care to identify those with high-risk symptoms of colorectal cancer, who are then classed as urgent and need to be seen within two weeks of the referral being written (see Table 2).(8) Patients can have any one or more of these symptoms.

[[NIP25_table2_53]]

There is also a need for further investigation, despite evident haemorrhoids, if the patient has a positive significant family history of bowel cancer - that is, if their first-degree relative was diagnosed at 45 years or younger or if there are two first-degree relatives of any age (first-degree relatives are parents, siblings or children). It is also important to note whether the patient has a history of bowel cancer or bowel polyps.

Treatments
The most effective treatment for haemorrhoids is prevention. Otherwise the least treatment possible should be instigated initially. Often haemorrhoids will settle down on their own. Treatment should be guided by the degree and severity of symptoms and with patient discussion about the effect on their everyday life. It's important to try to establish whether there had been a change in diet or lifestyle at the time of the onset of the symptoms.

Dietary advice
Encourage patients to increase fibre in their diet through fruit and vegetables, cereals and wholemeal bread. The average fibre intake is thought to be around 8-15g per day. With a high-fibre diet the aim would be 25g per day. Increasing fibre intake will often help to soften motions, thereby relieving constipation and thus reducing the need to strain.

General advice
As well as increasing fibre, it is important to increase fluid intake up to 10-12 cups a day (not including tea/coffee, which has a diuretic effect, increasing urine output but leaving less fluid in the gut), to exercise regularly, and avoid constipating analgesia and other medications that can disturb the gastrointestinal tract.
Ensure the patient listens to the "call to stool" by going to the toilet as the need is felt rather than putting it off as this causes the stool to become constipated.
Advise them to avoid straining and sitting on the toilet for long periods of time. Two booklets entitled Healthy Eating and Healthy Habits, available from the Food Standards Agency, contain useful information.
If constipation is a problem it is worth checking the patient's position on the toilet to ensure the best angle for easy defecation, leaning forward from the waist with feet placed on a raised area of about 10-20cm, approximately the size of a telephone directory.
Ideally this general, lifestyle and dietary advice is initiated and reviewed by the GP before a referral is written to a specialist colorectal clinic.
For painful prolapsed haemorrhoids the use of an ice pack pressed on and off at a few-minute intervals for 15-30 minutes may give some immediate relief. Also, a regular warm bath, putting feet up to promote venous return, and oral analgesia such as paracetamol and laxatives should help. Ointments and lignocaine gel have little or no effect with prolapsed or thrombosed haemorrhoids.

Medication
Fibre supplements in the form of psyllium husk, such as Fybogel, have been shown to reduce episodes of rectal bleeding and discomfort in those with internal haemorrhoids, but it may take about six weeks to see an improvement, and it does not reduce any prolapse. Osmotic laxatives such as lactulose act by drawing more fluid into the bowel and can help soften stool present, allowing it to pass easily without putting pressure on the haemorrhoids so they can settle down naturally. It is wise to avoid use of senna as its stimulant effect can make the symptoms worse.
One double-blind, placebo-controlled trial showed that the use of psyllium reduced haemorrhoidal bleeding and painful defecation, but other studies on fibre have shown less impressive results.(9,10)
However, Porrett found that a bulking agent with nurse-led education, advice and bowel habit retraining is as effective in reducing the incidence of bleeding from first- and second-degree haemorrhoids as injection sclerotherapy, and patients felt more informed and hence empowered.(11)
Often forgotten is that diarrhoea exacerbates haemorrhoidal symptoms as well as constipation, and controlling diarrhoea with fibre, supplements, anti-motility agents and specific treatment of any underlying cause will likely be of benefit.
There are a range of ointments used for haemorrhoids, which can contain local anaesthetics, mild astringents and steroids, in the form of suppositories and creams (eg, Xyloproct). They are commonly used as a short-term relief from the discomfort, but there is a lack of evidence to support their use. They do not affect the underlying pathological changes in the anal cushions but can cause desensitisation of the perianal area, eczema and thinning of the skin.
In one prospective series, glyceryl trinitrate ointment (GTN) (commonly used for treatment of anal fissures) relieved pain due to thrombosed external haemorrhoids, presumably by decreasing anal tone.(12)

Nonoperative treatments
These include injection sclerotherapy, diathermy coagulation, bipolar coagulation, infrared coagulation and rubber band ligation. Cryotherapy is no longer recommended due to the high complication rate and strong-smelling discharge. These treatments are most suitable for second- and third-degree haemorrhoids or when first-degree haemorrhoid medical treatment fails. These procedures can be repeated, and none requires anaesthesia. Each has its advantages and disadvantages. Randomised controlled trials have compared each method with one or more, yet no single study has compared all five.

Phenol injection therapy
This is one of the oldest forms of nonoperative measures for treating haemorrhoids, first described in 1869 by Morgan in Dublin.
Treatments performed in clinic are for first-degree haemorrhoids that have not responded to dietary and lifestyle changes, as well as second- and some third-degree haemorrhoids.
Using a proctoscope, a submucosal injection of approximately 3ml of 5% phenol in oil is placed into the base of the haemorrhoidal area, which causes the blood vessels to thrombose with shrinkage and fixation of the mucosa.
It takes minutes to do, and no anaesthesia is necessary, as it should be injected above the dentate line so there are no innervations and hence no pain.
Up to three injections six weeks apart can be given. Patients should be informed that they may feel a dull ache and rectal bleeding afterwards, and they should be advised to take preventative analgesia such as paracetamol after leaving the clinic.
There are complications with this treatment, which include pain (reported in 12-70%) and bleeding.(13,14) Rare complications include urinary retention, abscess pelvic infection,(6) impotence(15) and prostatitis as a result of incorrectly sited injections.

Rubber band ligation
Band ligation is the most effective outpatient procedure for haemorrhoids, providing a cure for 79% with first- to third-degree haemorrhoids.(16) There is relatively more discomfort than with other nonoperative techniques, but it has the lowest recurrence rate (there is a need for preventative advice to sustain this).
Proctoscopy identifies the haemorrhoid's origin, which is grasped either by using a type of forceps or, more recently, with suction. A band is then applied to the haemorrhoidal base and it is over in seconds and should be painless if applied above the dentate line. The pile becomes necrotic from the strangulation of the band and eventually sloughs off, while the underlying tissue undergoes fixation by fibrotic wound healing. This may take a few days, and the patient may see the band with tissue after a bowel movement.
Up to three piles can be banded at one visit, although this has been shown to increase the level of discomfort and risk of vasovagal and urinary symptoms compared with that of a single band. However, multiple banding does not increase the risk of major complications.(17) Injecting a local anaesthetic before multiple banding does not reduce the level of discomfort.(18)
Complications can occur if the band is placed too low causing immediate and severe pain due to squamous epithelium within the band. This requires prompt removal.
 
Conclusion
Treatments and surgery for haemorrhoids should be avoided if possible, especially in those at higher risk of complications. For example, patients with Crohn's disease can potentially have complex perianal complaints, therefore it is important that treatments are reserved until the disease is well controlled. In patients with HIV/AIDS there is a higher risk of infective/septic complication due to their immunosuppressed status.(19) Patients taking anticoagulation therapy (eg, warfarin) should avoid treatments/surgery due to the risk of excessive bleeding afterwards. Shemesh found that patients who were neutropenic or had severe diabetes mellitus were at risk of major complications.(20) It is advisable to avoid any interventions especially in the first trimester of pregnancy. In these groups of patients mentioned it is vital that all conservative therapies are fully discussed, implemented and reviewed.
There are multiple haemorrhoidal treatments, but conservative treatment should be initiated first for the smaller haemorrhoids with healthy eating advice, adequate fluid intake, exercise and bulking agents. If treatments are necessary, the appropriate health education needs to go alongside this to prevent recurrence of the problem. Surgery is effective, but there can be complications. Nurses have an important role in educating and informing patients about haemorrhoid prevention and advice.

References

  1. Brandt LJ. Emerg Med 2004 Jan.
  2. Thompson WH. Br J Surg 1975;62:542-52.
  3. Banov L Jr, Knoepp LF Jr, Erdman LH, Alia RT. J S C Med Assoc 1985;81:398-401.
  4. Delco F, Sonnenberg A. Dis Colon Rectum 1998;41:1534-41.
  5. Williams NS. Haemorrhoidal disease. In: Keighley RB, Williams NS. Surgery of the anus, rectum, colon. Vol 1. London: WB Saunders; 1993.
  6. Bleday R, Pena JP, Rothenberger DA, Goldberg SM, Buls JG. Dis Colon Rectum 1992;35:477-81.
  7. American Society for Gastrointestinal Endoscopy (ASGE). Gastrointest Endosc 1998;34:179-82.
  8. Department of Health. Referral guidelines for suspected cancer. London: NHS Executive; 2000.
  9. Perez-Miranda M, Gomez-Cedenilla A, Leon-Colombo T, Pajares J, Mate-Jimenez J. Hepato gastroenterology 1996;43:1504-7.
  10. Webster DJ, Gough DC, Craven JL. Br J Surg 1978;65:291-2.
  11. Porrett TR, Lunniss PJ. Colorectal Dis 2001;3(4) 227-31.
  12. Gorfine SR. Dis Colon Rectum 1995;38:453-6.
  13. Walker AJ, Leicester RJ, Nicholls RJ, Mann CV. Int J Colorectal Dis 1990;5:113-6.
  14. Sim AJ, Murie JA, Mackenzie I. Sur Gynecol Obstet 1983;157:534-6.
  15. Bullock N. BMJ 1997;314;419.
  16. MacRae HM, McLeod RS. Can J Surg 1997;40:14-7.
  17. Lee HH, Spencer RJ, Beart RW Jr. Dis Colon Rectum 1994;37:37-41.
  18. Law WL, Chu KW. Dis Colon Rectum 1999;42:363-6.
  19. Morandi E, Merlini D, Salvaggio A, Foschi D, Trabucchi E. Dis Colon Rectum 1999;42:1140-4.
  20. Shemesh EI, Kodner IJ, Fry RD, Neufeld DM. Dis Colon Rectum 1987;30;199-200.

Resources
Food Standards Agency
W:www.food.gov.uk

Digestive Disorders Foundation
W:www.digestive disorders.org.uk