Haemorrhoids

Haemorrhoids, also known as piles, are a common condition. They occur when the small veins that line the anal canal become swollen with more blood than usual and start causing pain, anal itching and bleeding, and as they enlarge, form one or more small lumps ('piles') just outside the anal margin.

They are the commonest cause of bleeding from the back passage and affect men and women equally. Approximately one in three adults in the UK will experience haemorrhoids at some point in their lives. Most people with haemorrhoids tolerate intermittent symptoms, but severe cases require specialist treatment.

• Internal — these generally remain inside the anal canal, and can become symptomatic, usually causing soreness, itching and bleeding. They can also hang down and prolapse through the anus over time.
• External — the skin component of the haemorrhoids becomes more prominent and often causes difficulty with hygiene as well as discomfort.
• Thrombosed — occasionally, haemorrhoids may become extremely painful because of a clot inside them and cause a large purple lump to form outside the back passage. The lump and the pain usually gradually subside over a period of a week or two.

Grading

• Grade I — bleed and are uncomfortable, but remain inside the anus.
• Grade II — prolapse after passing a stool, but go back inside on their own afterwards.
• Grade III — prolapse after passing a stool but need to be pushed back inside the anus.
• Grade IV — always prolapsed and can't be pushed back inside. If the blood inside them clots, they become thrombosed haemorrhoids, which bleed and are very painful.

• Bright red bleeding on the toilet paper or in the toilet bowl (usually painless).
• Itching, irritation or soreness around the anus.
• A lump or swelling near the anus (may be tender or painful).
• Pain with bowel movements (especially with external or thrombosed haemorrhoids).
• Mucus discharge or a feeling of incomplete bowel emptying.

The reason why some people develop haemorrhoids and others do not is not known, but studies have shown that their development is usually connected to a rise in pressure in the anal canal, which can be caused by constipation, straining on the lavatory and pregnancy.

They don't tend to cause serious problems, but rarely, they can cause anaemia if the bleeding is severe and persistent, or they can become strangulated, whereby the blood supply becomes affected, and they become very large and extremely painful.

Correct diagnosis of haemorrhoids is extremely important because much more serious conditions such as anal or rectal cancer can occasionally give the same symptoms as haemorrhoids. So, it is very important that you ask a GP or specialist doctor to examine your bottom if you have anal or bowel symptoms.

Haemorrhoids are diagnosed mainly on symptoms and physical examination. This usually involves a digital rectal examination and a proctoscopy, which is a small tube with light at the end to view the lining of your anus and rectum. These tests may be uncomfortable, but they aren't painful and they take place in the outpatient clinic.

Smaller haemorrhoids can respond to some topical ointments containing local anaesthetic and/or steroids (which can only be used for up to a week). It's also very important to keep the area clean after a bowel motion, preferably with wet wipes or washcloth moistened with water if possible.

Rubber band ligation

If the symptoms persist and become troublesome, then Mr Lamah's recommendation at that stage is to try rubber band ligation. This is only possible in patients who have large internal haemorrhoids and the procedure attempts to achieve two main effects: firstly, to interrupt the blood flow within the venous channels of the submucosa, and secondly to cause inflammation in the submucosa which creates scarring and stops the mucosa slipping and prolapsing.

The bands are placed above the haemorrhoid where there are no pain fibres (nerves). The procedure is carried out in outpatients and takes just a few minutes; it is extremely safe and causes minimal discomfort afterwards, for which a simple painkiller such as Paracetamol usually suffices. The success rate is variable and the procedure can be repeated as often as necessary.

Surgical options

If these simple measures do not help and the symptoms continue to be significant and persistent, then surgical options can be discussed, and on the whole, depending on the type of haemorrhoid, are very effective in the short and long term. There are several surgical techniques, and Mr Lamah decides which one to use at the time of surgery, depending on the exact anatomy and extent of the haemorrhoids.

Haemorrhoidectomy

Haemorrhoidectomy consists of the excision of the haemorrhoids using a sharp instrument, such as a scalpel, scissors, electrocautery, or even laser. Mr Lamah tends to leave the resulting wound open (some surgeons close the wound) as this reduces the risk of post-operative infection. Potential complications include pain, infection, delayed bleeding, urinary retention, faecal impaction, and very rarely, faecal incontinence, and anal stricture.

Although this technique has the most postoperative discomfort and pain, when carried out expertly, it does have the best long-term results with the lowest recurrence rates. Mr Lamah has performed over 1000 haemorrhoidectomies during his 25 year consultant career, with excellent results.

Other techniques

In transanal hemorrhoidal dearterialisation (THD), internal haemorrhoids are tied off and pulled back into your rectum with sutures.

Stapled haemorrhoidopexy (also called Longo's procedure) is mostly used in patients with large, circumferential internal haemorrhoids, not amenable to the surgical excision technique described above, or if banding has failed. During stapled haemorrhoidopexy, a circular stapling device is used to excise a circumferential ring of excess haemorrhoidal tissue, thereby lifting haemorrhoids back to their normal position within the anal canal. Stapling also disrupts haemorrhoidal blood supply.

Recovery

Following any of the above procedures, you will receive advice about wound care, activity restrictions, and return-to-work timelines from your hospital team. You should keep bowel motions soft and regular with the aid of laxatives and you will need to take regular pain killers for a week or two after the procedure. Depending on your type of activity and the procedure done, you will need to take a couple of weeks off before returning to normal activities.