What are they?
Haemorrhoids or piles are dilated venous blood channels that arise from the veins draining the area just inside the back passage. These venous lumps start small and are only visible by looking inside the bowel but in time enlarge and may be so large that they fall through the back passage all the time.
External haemorrhoids are dilation of venous channels outside the back passage and are quite a different problem to the usual “piles”.
Pressure receptors within the mucosa will often register a dull, throbbing pain with large haemorrhoids but the most common presentation is a small amount of painless bright blood passed rectally. The blood is often seen just on the toilet paper or described as “dripping” into the toilet. The lumps may be palpated and sometimes prolapse (fall through) only after a bowel motion is passed before retracting back. The haemorrhoid veins are cushions which contribute to bowel continence and when they enlarge through the opening they may cause soiling of faeces or mucous. This soiling can cause irritation and itching around the back passage. It can be difficult to keep this area dry and clean if the haemorrhoids are large and prolapsing.
The most common cause of haemorrhoids is chronic constipation. Straining at stool for years causes poor venous outflow and the haemorrhoids enlarge. Other causes are pregnancy, severe liver disease, general frailty and some patients just have a familial disposition to these problems.
The most important principle is to modify the stool consistency and defaecation habits. The bowel action should be softly formed and dietary manipulation may be required. Fibre content in the diet should be increased to 20-30 gm daily, preferably fibre in fruit and vegetables. Drink at least 6-8 glasses of fluid daily.
Straining at stool must be avoided. Rather than straining the undercarriage muscles the diaphragm should be used “like a coffee plunger” to increase intra-abdominal pressure to aid evacuation.
There are haemorrhoid preparations available from the pharmacy and they can be of moderate benefit. These creams, ointments or suppositories contain local anaesthetic, steroids, antiseptics, drying agents and drugs to decrease venous size. If the haemorrhoids prolapse and cause pain, applying gentle cold pressure with your finger or ice pack can be helpful in the short term to ease the discomfort.
Large haemorrhoids need more aggressive therapy if they are troublesome. The most common method of management is to apply a tight rubber band to the area. The ligated haemorrhoid will thrombose and fall off in 7-10 days. Some patients require narcotics for pain relief for 1-2 days but most people need only Paracetamol. The band will drop off in about 10 days and a small amount of bleeding may be noted at this time.
Complications are rare but severe pain may continue for days, ulceration may occur and cause infection or late bleeding. Severe pain can sometimes cause urinary obstruction. Occasionally the bands will fall off prematurely and fail to thrombose the haemorrhoids. Haemorrhoids may recur after banding. Death is a remote possibility with any endoscopic procedure.
After the ligation you must keep your bowel motion soft, use a stool-softening laxative if necessary. Don’t strain at stool. Avoid heavy lifting for 2 weeks. Use painkillers if necessary but avoid Aspirin. Warm salt baths may help relieve discomfort.
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