Colon Issues

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HAEMORRHOIDS

Haemorrhoids, also known as piles, are part of anal canal. They cause a trouble when they become enlarged, swollen or inflammed. Under the normal circumstances they act as cushions composed of vessels and surrounding tissue that aid the passage of stool.

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HAEMORRHOIDS

Haemorrhoids, also known as piles, are part of anal canal. They cause a trouble when they become enlarged, swollen or inflammed. Under the normal circumstances they act as cushions composed of vessels and surrounding tissue that aid the passage of stool.

What types of haemorrhoids do we know and what are the symptoms?

There are two types of haemorrhoids external and internal which are differentiated via their position with respect to the dentate line.

External

External haemorrhoids are those that occur outside the anus. They are sometimes painful, and often accompanied by swelling and irritation. Itching, although often thought to be a symptom of external haemorrhoids, is more commonly due to skin irritation. External haemorrhoids are prone to thrombosis. This happens if the vein ruptures and/or a blood cloth develops within the haemorrhoid.

Internal

Internal haemorrhoids are those that occur inside the rectum. Internal haemorrhoids are usually painless and most people are not aware that they have them. Internal haemorrhoids, however, may bleed when irritated. Normally, the bleeding is limited to small stains of fresh blood on the toilet paper, but more severe bleeding may occur during passing a hard stool. When internal haemorrhoids are large, they may prolaps outside the anus.

Internal haemorrhoids can be further graded by the degree of protrusion from the anus (prolaps). Pictures are taken during the endoscopy.

• Grade I: Haemorrhoids bulge into the lumen of anal canal but do not protrude out of the anus.

• Grade II: Haemorrhoids prolapse upon defecation but spontaneously reduce.

• Grade III: Haemorrhoids prolapse upon defecation, but must be manually reduced.

• Grade IV: Haemorrhoids prolapsed and cannot be manually reduced.

How common are haemorrhoids?

Haemorrhoids are very common in both men and women. About half of the population have haemorrhoids by age 50.

What are the causes?

A number of factors may lead to the formations of haemorrhoids including irregular bowel habits, constipation, diarrhea, exercise, pregnancy, nutrition (low-fiber diet), increased intra-abdominal pressure (prolonged straining), obesity, sitting for long periods of time and aging.

How are haemorrhoids prevented?

The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining and to empty bowels as soon as possible after the urge occurs. Exercise including walking, high fibre diet and adequate water intake help reduce constipation and straining by producing stools that are softer and easier to pass.

How are haemorrhoids diagnosed?

A thorough evaluation and proper diagnosis is important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.
Anus and rectum will be will examined for swollen blood vessels that indicate haemorrhoids. A digital rectal exam will be performed to feel for abnormalities. Closer evaluation of the rectum for haemorrhoids requires an exam with an proctoscope, a hollow tube useful for viewing internal haemorrhoids.
To rule out other causes of gastrointestinal bleeding, the entire colon will be examined with colonoscopy (see the section on colonoscopy).

What is the treatment?

1. Lifestyle Modifications
Small haemorrhoids can get better even without medical treatment. If they are caused by constipation, the aim of the treatment is to achieve regular soft stools. A softer stool makes emptying the bowels easier and lessens the pressure on haemorrhoids caused by straining. The most important measurement is a change of diet with the addition of more fibre and roughage particularly green vegetables, fresh fruit, wholegrain cereals and bran. Fluid intake should be increased to 8 to 10 glasses (2L) of fluid daily.
The patient is also advised to avoid straining when passing a stool. Sitting in a shallow bath of hot water for 15 minutes several times a day, will reduce the pain.

2. Medication
Relatively small haemorrhoids can be treated using creams or suppository (Proctosedyl) together with medication (Daflon).

3. Rubber Band Ligation
More severe cases need to be treated by a specialist. One possible treatment is rubber band ligation. Rubber band ligation is performed as outpatient procedure and does not require hospital admission. The procedure involves placing a small rubber band at the base of the haemorrhoid with a special applicator. The rubber band cuts off the blood supply to the haemorrhoid, which eventually falls off after a few days. Cure rate has been found to be about 87%.

Who Is It Used For?

This technique is effective for treating moderate size haemorrhoids.

Who Shouldn’t Get This Procedure?

Rubber band ligation is not appropriate for treating large or bulky haemorrhoids. Haemorrhoids that are previously treated with sclerotherapy are difficult to band, and therefore should not be treated with this procedure.

Rubber Band Ligation Procedure

1. Pre-operative Medications

Prior to the procedure, the patient is advised not to take any medications that can cause bleeding, such as warfarin.

Pre-operative antibiotics are usually prescribed if the patient is taking steroid medications, has immune system deficiency, or has implanted prosthetic devices such as artificial joints or heart valves.

2. Enema

The patient is usually given an enema to clear the rectum of any stool.

3. Position

The most common position is the left lateral position, where the patient is laid down on the left side with knees drawn up.

4. Application of Band

The procedure involves placing a small rubber band at the base of the haemorrhoid with a special applicator.

Complications

Some possible complications of this procedure are:

1. Pain

Mild pain or a feeling of pressure is normal and should go away within one to two hours. Local pain killer cream can be applied onto the site of the application to help alleviate mild pain.
If severe or sharp pain occurs immediately after band application, this is caused placement of the band too low in the anal canal. In this case, the band should be removed, and re-applied at locations further above the dentate line.

2. Bleeding

Mild bleeding normally occur at the first bowel movement after the procedure. Very rarely the bleeding is severe and requires hospitalization.

When the haemorrhoid shrivels and falls off few days after the procedure, some bleeding may occur.

3. Band slippage

Slippage of the band can occur if haemorrhoids are too small.

4. Other complications

Infection, blood cloth and anal fissure are other rare complications which require further intervention.

Post-procedure instructions for patients

• Patient may experience some bleeding, especially after bowel movements. This may last for several days or more. If the patient thinks it is severe or persistent, the patient should contact his/her doctor.
• Paracetamol could be taken for any discomfort the patient may feel.
• A warm bath for about 10 minutes, 2-3 times a day, may help.
• No heavy lifting or strenuous activities for 3-4 days.
• A stool softener (Lactulose) is recommended once a day for about 3 days.
• Patient should avoid straining during bowel motion.

4. Sclerotherapy

• Injection of a substance that makes the blood in the haemorrhoid clot is another option (sclerotherapy). This procedure is more painful than rubber band ligation. The success rate at four years is 70%.

5. Surgery

If the haemorrhoids are too large and they protrude through the back passage and cannot be manually reduced, the treatment requires surgical removal or ‘haemorroidectomy’. Such operations are successful in 90 per cent of cases. However, many third-degree haemorrhoids shrink and become symptom-free even without surgical treatment.

After surgery

After haemorrhoids have been removed, small skin tags can develop beside the back passage. In some cases they will be slightly painful or itchy and if so they can also be surgically removed by a minor operation.
Following any treatment for haemorrhoids, it is very important to avoid constipation and straining or the condition may recur.