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When blood vessels in and around the anus are bulged, they can lead to stretching of the anus mucosa. There are many factors that can cause hemorrhoids, but it is often hard to specify one. When the veins become excessively swollen and distended, it may cause bleeding in and around the anus or prolapse of the anus mucosa.
The symptom is called hemorrhoids, and they are one of the most common diseases in human history. About ⅓ or half of the human population experiences hemorrhoids during their lifetime.
Sliding Anal Lining Theory
When a person gets older, the supporting tissues of the anal cusions get weakened. Human’s daily bowel movement can irritate the anus mucosa regularly, and it may lead to the abnormal downward displacement (=sliding or prolapse) of the anal tissues that are located under the mucosa. You can actually see under a microscope that a person’s submucous suspensory ligament loses its functional ability when he/she reaches his/her thirties.
The theory of varicose vein which postulated that hemorrhoids were caused by varicose veins in the anal canal had been widely accepted, but it is now considered obsolete, and the sliding anal lining theory is more accepted by the medical community and academia.
There is a soft yet sturdy mucous membrane called anal cushion that prevents anal canal from abrasion during bowel movement. When the cushion is bulged to an abnormal degree, it is called hemorrhoid. In short, when bulged blood vessels in an anal cushion results in a stretched, slided anus mucosa, it is called ‘hemorrhoid’. This can develop from increased pressure in the lower rectum, such as straining too much during bowel movements, prolonged standing, and heavy lifting.
Symptoms of hemoorhoids?
Prolapse of the anal mucosa
Many patients who are experiencing pain in anus or problems with bowel movement think that they are having hemorrhoids, but in many cases they are diagnosed with other diseases. By carefully listening to and examining the patients’ symptoms, doctors can make accurate diagnosis.
Hemorrhoids usually involve bleeding, prolapse of anal mucose, pain, sense of blockage in your rectume that prevents smooth bowel movement, mucus secretion, difficulties in wiping anus after defecation, deformation of anal tissues, and pruritus in anus.
Anal bleeding occurs in the first degree internal hemorrhoids, usually involves spilling of bright red blood after defecation. Bleeding is the most common symptom, so if you are not bleeding, you are less likely to be diagnosed with hemorrhoids. When the amount of bleeding is small, it is nothing more than blood blots, but if the hemorrhoid is severe, it can even result in blood squirting.
Usually, anal bleeding with severe pain is more likely to be discovered as an anal fissure rather than hemorrhoids. If you are seeing dark, deep crimson blood, it is more likely to be rectal or colorectal cancer.
In some cases, an internal hemorrhoid can be enlarged to the degree in which it exposes itself to the outside of an anus, but it doesn’t necessarily involve bleeding. If the prolapsed hemorrhoid naturally goes back to the normal position, it is a second degree internal hemorrhoid, if you need to artificially push it into the right position, it is a third degree, and if you cannot move it to the right position even with your finger pressure, it is called a fourth degree.
1st degree internal hemorrhoid
It does not slide out of anus, but it bleeds sometimes.
2nd degree internal hemorrhoid
It frequently slides in and out of anus.
3rd degree internal hemorrhoid
It does not stay in your anus unless you push it into it.
4th degree internal hemorrhoid
It does not stay in the right position even with external pressure, and it causes pain and necrosis around the affected area.
Pregnancy can also increase anal pressure, increasing the incidence rate of hemorrhoids. Therefore, it is important to avoid extra pressure on your anus and prevent constipation.
On the other hand, when you have an external hemorrhoid, you may feel a lump near your anus. If the blood vessel in the hemorrhoid bursts and develops blood clots, they can involve extreme pain and become a solid, hard lump. They are called thrombosed hemorrhoids.
Drinking too much alcohol, putting excessive pressure and straining around the anus as a result of constipation, and sitting on cold surfaces for a long period of time in winter may cause thrombosed hemorrhoids.
Other symptoms of hemorrhoids include mucus secretion and pruritus. Internal hemorrhoids can cause leakage of anal mucus accompanied by anal prolapse. Also, external hemorrhoids usually make it difficult to clean the anal area after bowel movements, so it can leave residues. They all can cause pruritus.
First, we will ask you several questions about the color of the blood on the tissue or level of pain after having a bowel movement.
Then you will enter the examination room for visual inspection, to see if there is any downward displacement of anal tissues.
Your doctor might insert a globed, lubricated finger into your rectum to see if there are any other separate lumps that are not hemorrhoids. Depending on your symptoms and medical history, your doctor may order an additional test like an anoscopy, which involves a tubular instrument called anoscope. An anoscopy test can help doctors easily find hemorrhoids and examine the severity of symptoms. After the test, you will be guided back to the doctor's office to hear the doctor’s explanation of the digital data on the screen.
Treatment of Hemorrhoids?
Non-Surgical Treatments of Hemorrhoids
· Water intake and diet:
Fiber-rich foods including fruits, vegetables, beans, and brown rice can add bulk to stools and soften them.
Spending 30 minutes every day on aerobic exercises to stimulate the muscle movements of your internal organs can encourage the colon’s movement, and thus move the stools that have been stuck in the right colon to the transverse colon, and eventually, to the left colon.
Regular sitz-bath can relax anus sphincter, reduce the pain of muscle convulsions, cleanse the anus area, and promote thromboclasis and skin’s wound healing process.
· Drug Therapy:
- Fiber capsules that swell in the digestive organs - Stool softeners that help stools pass easier - Drugs that support health of the blood circulatory system - Anti-inflammatory and analgesic medicines - Ointments and suppositories to increase blood flow and reduce inflammation.
· Supplementary Treatments
01 Sclerotherapy with ALTA (Aluminum potassium sulfate and tannic acid) injection
injecting sclerosing agents is one of the most effective ways to treat hemorrhoids and anus bleeding without surgery. It is less painful than surgeries that involve resection and requires less amount of pain relievers, according to recent scientific research. However, use of the treatment is limited to the patients who are experiencing mild symptoms, lower than second degree hemorrhoids. It is appropriate for patients whose hemorrhoids involve only bleeding.
02 Rubber Band Ligation
It is mostly used for treating 2nd degree hemorrhoids. The treatment is relatively simple and it does not require any inpatient treatment. 1st to early 3rd degree hemorrhoids that involve bleeding and mild anal prolapse can be effectively cured by this method. Rubber band ligation is a procedure in which the hemorrhoid is double-tied off at its base with rubber bands to stop blood flow to the hemorrhoid. It does not require any resection, so it is virtually painless and does not involve any rectal bleeding.
Surgical Treatments of Hemorrhoids
· A Banana Clip
01 Advantages of a Banana Clip
Until a few years ago, doctors usually ligated the hemorrhoids with rubber rings and cut them off, which involved a high level of pain. However, now we use an instrument called ‘banana clip’ that is made out of polymers to ligate the hemorrhoids, which significantly reduced pain and lowered the possibility of secondary bleeding. It is virtually painless when the clip falls out of the anus, and there is no stenosis in the anus area. The operation time is significantly reduced, too.
In the past, doctors tried to resect the affected area as much as possible, and surgeries necessarily involved diverse complications. Now, surgeries do not require resection of large pieces of tissues, so the complications are minimized.
· Traditional surgical methods with scalpel
01 Milligan-Morgan Type (excision and ligation)
02 Ferguson Type (high ligation and complete closure)
03 Parks Type (submucosal hemorrhoidectomy)
04 Takano Type (from Japan) (anoderm-cushion sparing hemorrhoidectomy)
Modern surgical methods with our cutting-edge medical devices
Lasers can substitute the traditional roles of scalpel and can be used for excision.
· Harmonic Scalpel (Ultrasonic scissors):
They can remove the affected area and heal the wounds at the same time. The ultrasonic waves at about 55.000 vibrations per second can resect the affected area, which can preserve the normal tissues as much as possible, and stimulate the wound-healing process.
· Doppler-Guided Hemorrhoidal Artery Ligation:
Dopplers may be used for identifying the hemorrhoidal artery that is supplying blood to the hemorrhoids. It can help doctors selectively ligate the artery. The method is usually used for treatment of 1st and 2nd degree hemorrhoids. It is virtually painless and involves only a small amount of bleeding during and after the surgery.
· PPH (Procedure for Prolapsed Hemorrhoids, also called circular stapled hemorrhoidectomy):
It uses a circular stapler to remove the hemorrhoids and the nearby rectal mucosa areas, located 3~4cm above the rectum. It does not injure the anus mucosa that is causing pain, so it is virtually painless and does not require a long period of recovery time.
01 Steps of the PPH Surgery
1) Insert a purse-string anoscope to place a circumferential mucosal and submucosal suture, 3~4cm above the dentate line in a clockwise manner using a transanal stapler.
2) Then, the stapler is closed and fired, excising a circumferential strip of mucosa and submucosa from the proximal anal canal, with automatic closure of the defect by the stape ring, placed approximately 2cm above the dentate line.
Prevention of Hemorrhoids?
It is vital to prevent and treat constipation in the early stage, because constipation is one of the main reasons for the occurrence and exacerbation of hemorrhoids.
You need to avoid reading books or newspapers or using smartphones in the toilet. It is a very bad habit that prolongs the time you are staying there, which can have negative effects on your blood circulation. Sitting in the same position for a long time can stagnate the blood flow in the anus and may cause bleeding and hemorrhoids. You don’t need to empty all of your stools every time, so do not pose excessive pressure to the area.
Sitz-bath in lukewarm water or using a bidet can facilitate blood circulation, which can reduce the edema of the mucosa.
Please stop drinking alcohol, as alcohols can expand blood vessels and it may exacerbate the symptoms of hemorrhoids like bleeding and edema.
Please stop drinking alcohol, as alcohols can expand blood vessels and it may exacerbate the symptoms of hemorrhoids like bleeding and edema.
Avoid sitting on a cold surface for a long period of time, as it can cause acutely thrombosed external hemorrhoids. Please have a sitz-bath or take a shower in lukewarm water after spending a long period of time in cold weather.
Visit a hospital to have a thorough examination
· If you are having bleeding in anus,
it is likely that you are having hemorrhoids or anal fissure, but it can be a colorectal cancer so please visit a hospital to have a thorough examination.
· If an anal prolapse is causing severe pain,
it can be a thrombosed external hemorrhoid or a strangulated hemorrhoid, which require surgical treatments.
· If the edema or the pain is exacerbated,
it is highly likely that you need surgeries.
· If the bleeding is unusually severe or does not stop,
only surgery can cure the disease.
· If you are in or above fifties and you are experiencing diarrhea for more than 15 days,
it can be a colorectal cancer so please visit a hospital as soon as possible.
· If your symptoms include severe constipation,
you need to examine its causes.
· If you can feel a lump in your anus or abdomen,
you need to identify the name of the disease or remove the blood clots.
The wrong informations about the surgery
· It can involve severe pain,
but recently, new, developed ways of resection surgeries and innovative medical devices are introduced, and significantly reduced the during- and post-surgery pain. Pain relieving medications and devices have also been developed, so you don’t need to worry a lot.
· Many female patients say that they feel embarrassed to visit hospitals to cure anal diseases.
In the past, many hospitals actually did not prepare a measure to protect the female patients’ privacy. However, many medical practitioners are now aware of the issue and trying their best to care for them. If you request before your consultation, we will match you with a female doctor.
· Can hemorrhoids re-emerge after the surgery?
Surgery for acute appendicitis requires removal of the appendix, so there is no chance of re-emergence. However, we try our best not to remove your anus, to preserve it as long as possible during your lifetime. Every disease that occurs in internal organs has a chance of re-emergence, but the surgical methods are highly developed now, so hemorrhoids have little possibility of re-emergence. However, please put efforts in checking your daily defecation habits, preventing constipation, and avoiding drinking even after the surgery.
· Will the anus be narrowed after the surgery (anus stenosis)?
If you resect great amount of tissue, then it can leave a scar and stretch the tissue and cause an anal stenosis. But as explained above, recent surgery methods do not require resection of a wide area, so it rarely occurs.
· Can the anal or rectal surgery cause fecal incontinence?
If your skin is cut too deep during the surgery, it can injure anal sphincters and reduce their ability to contract and maintain continence. However, it is a rare mistake because most of the proctologists have a high level of expertise in anatomy of the human anus. Also, doctors usually are able to see the actual internal and external anal sphincters, so it is hardly likely to happen.
We understand that many patients are very hesitant to receive anal surgery for the possible side effects mentioned above, but if you leave the disease untreated, it can only exacerbate it and thus will eventually require a more complex surgery and increase the magnitude of surgical site and the pain that follows the surgery.