Medical term:

hemorrhoids

Hemorrhoids

Definition

Hemorrhoids are enlarged veins in the anus or lower rectum. They often go unnoticed and usually clear up after a few days, but can cause long-lasting discomfort, bleeding and be excruciatingly painful. Effective medical treatments are available, however.

Description

Hemorrhoids (also called piles) can be divided into two kinds, internal and external. Internal hemorrhoids lie inside the anus or lower rectum, beneath the anal or rectal lining. External hemorrhoids lie outside the anal opening. Both kinds can be present at the same time.

Hemorrhoids are a very common medical complaint. More than 75% of Americans have hemorrhoids at some point in their lives, typically after age 30. Pregnant women often develop hemorrhoids, but the condition usually clears up after childbirth. Men are more likely than women to suffer from hemorrhoids that require professional medical treatment.

Causes and symptoms

Precisely why hemorrhoids develop is unknown. Researchers have identified a number of reasons to explain hemorrhoidal swelling, including the simple fact that people's upright posture places a lot of pressure on the anal and rectal veins. Aging, obesity, pregnancy, chronic constipation or diarrhea, excessive use of enemas or laxatives, straining during bowel movements, and spending too much time on the toilet are considered contributing factors. Heredity may also play a part in some cases. There is no reason to believe that hemorrhoids are caused by jobs requiring, for instance, heavy lifting or long hours of sitting, although activities of that kind may make existing hemorrhoids worse.

The commonest symptom of internal hemorrhoids is bright red blood in the toilet bowl or on one's feces or toilet paper. When hemorrhoids remain inside the anus they are almost never painful, but they can prolapse (protrude outside the anus) and become irritated and sore. Sometimes, prolapsed hemorrhoids move back into the anal canal on their own or can be pushed back in, but at other times they remain permanently outside the anus until treated by a doctor.

Small external hemorrhoids usually do not produce symptoms. Larger ones, however, can be painful and interfere with cleaning the anal area after a bowel movement. When, as sometimes happens, a blood clot forms in an external hemorrhoid (creating what is called a thrombosed hemorrhoid), the skin around the anus becomes inflamed and a very painful lump develops. On rare occasions the clot will begin to bleed after a few days and leave blood on the underwear. A thrombosed hemorrhoid will not cause an embolism.

Diagnosis

Diagnosis begins with a visual examination of the anus, followed by an internal examination during which the doctor carefully inserts a gloved and lubricated finger into the anus. The doctor may also use an anoscope, a small tube that allows him or her to see into the anal canal. Under some circumstances the doctor may wish to check for other problems by using a sigmoidoscope or colonoscope, a flexible instrument that allows inspection of the lower colon (in the case of the sigmoidoscope) or the entire colon (in the case of the colonoscope).

Treatment

Hemorrhoids can often be effectively dealt with by dietary and lifestyle changes. Softening the feces and avoiding constipation by adding fiber to one's diet is important, because hard feces lead to straining during defecation. Fruit, leafy vegetables, and wholegrain breads and cereals are good sources of fiber, as are bulk laxatives and fiber supplements such as Metamucil or Citrucel. Exercising, losing excess weight, and drinking six to eight glasses a day of water or another liquid (not alcohol) also helps. Soap or toilet paper that is perfumed may irritate the anal area and should be avoided, as should excessive cleaning, rubbing, or wiping of that area. Reading in the bathroom is also considered a bad idea, because it adds to the time one spends on the toilet and may increase the strain placed on the anal and rectal veins. After each bowel movement, wiping with a moistened tissue or pad sold for that purpose helps lessen irritation. Hemorrhoid pain is often eased by sitting in a tub of warm water for about 10 or 15 minutes two to four times a day (sitz bath). A cool compress or ice pack to reduce swelling is also recommended (the ice pack should be wrapped in a cloth or towel to prevent direct contact with the skin). Many people find that over-the-counter hemorrhoid creams and foams bring relief, but these medications do not make hemorrhoids disappear.

When painful hemorrhoids do not respond to home-based remedies, professional medical treatment is necessary. The choice of treatment depends on the type of hemorrhoid, what medical equipment is available, and other considerations.

Rubber band ligation is probably the most widely used of the many treatments for internal hemorrhoids (and the least costly for the patient). This procedure is performed in the office of a family doctor or specialist, or in a hospital on an outpatient basis. An applicator is used to place one or two small rubber bands around the base of the hemorrhoid, cutting off its blood supply. After three to 10 days in the bands, the hemorrhoid falls off, leaving a sore that heals in a week or two. Because internal hemorrhoids are located in a part of the anus that does not sense pain, anesthetic is unnecessary and the procedure is painless in most cases. Although there can be minor discomfort and bleeding for a few days after the bands are applied, complications are rare and most people are soon able to return to work and other activities. If more than one hemorrhoid exists or if banding is not entirely effective the first time (as occasionally happens), the procedure may need to be repeated a few weeks later. After five years, 15-20% of patients experience a recurrence of

Rubber band ligation is probably the most widely used treatment for internal hemorrhoids. An applicator is used to place one or two small rubber bands around the base of the hemorrhoid, cutting off its blood supply (figures A and B). After 3-10 days, the rubber bands and the hemorrhoid fall off, leaving a scab which disappears within a week or two.

(Illustration by Electronic Illustrators Group.)

internal hemorrhoids, but in most cases all that is needed is another banding.

External hemorrhoids, and some prolapsed internal hemorrhoids, are removed by conventional surgery in a hospital. Depending on the circumstances, this requires a local, regional, or general anesthetic. Surgery does cause a fair amount of discomfort, but an overnight hospital stay is usually not necessary. Full healing takes two to four weeks, but most people are able to resume normal activities at the end of a week. Hemorrhoids rarely return after surgery.

Alternative treatment

Like mainstream practitioners, alternative practitioners stress the importance of a high-fiber diet. To prevent hemorrhoids by strengthening the veins of the anus, rectum, and colon, they recommend blackberries, blueberries, cherries, vitamin C, butcher's broom (Ruscus aculeatus), and flavonoids (plant pigments found in fruit and fruit products, tea, and soy). Herbal teas, ointments, and suppositories, and other kinds of herbal preparations, are suggested for reducing discomfort and eliminating hemorrhoids. In particular, pilewort (Ranunculusficaria), applied in an ointment or taken as a tea, can reduce the pain of external hemorrhoids. Acupuncture, acupressure, aromatherapy, and homeopathy are also used to treat hemorrhoids.

Prognosis

Hemorrhoids do not cause cancer and are rarely dangerous or life threatening. Most clear up after a few days without professional medical treatment. However, because colorectal cancer and other digestive system diseases can cause anal bleeding and other hemorrhoid-like symptoms, people should always consult a doctor when those symptoms occur.

Key terms

Anus — The opening at the lower end of the rectum. The anus and rectum are both part of the large intestine, a digestive system organ.

Colon — The major part of the large intestine, a digestive system organ.

Defecation — Passage of feces through the anus.

Embolism — Obstruction of blood flow in an artery by a blood clot or other substance arising from another site. An untreated embolism can endanger health and even cause death.

Enema — The introduction of water or another liquid into the bowels through a tube inserted into the anus. Enemas are used to treat constipation and for other purposes.

Feces — Undigested food and other waste that is eliminated through the anus. Also called stools.

Rectum — The lower section of the large intestine, a digestive system organ. After food has passed through the stomach and intestines and been digested, the leftover material, in the form of feces, enters the rectum, where it stays until defecation.

Suppository — A medicinal substance that slowly dissolves after being inserted into the rectum (or other body cavity).

Prevention

A high-fiber diet and the other lifestyle changes recommended for coping with existing hemorrhoids also help to prevent hemorrhoids. Not straining during bowel movements is essential.

Resources

Organizations

National Digestive Diseases Information Clearinghouse. 2 Information Way, Bethesda, MD 20892-3570. (800) 891-5389. http://www.niddk.nih.gov/health/digest/nddic.htm.

hem·or·rhoids

(hem'ŏ-roydz),

A varicose condition of the external hemorrhoidal veins causing painful swellings at the anus.

Synonym(s): piles

[G. haimorrhois, pl. haimorrhoides, veins likely to bleed, fr. haima, blood, + rhoia, a flow]

Farlex Partner Medical Dictionary © Farlex 2012

hemorrhoids

Lump in the rectum, piles Surgery Engorged veins under the rectal mucosa, associated with constipation, straining while squatting, pregnancy, prolonged sitting, anal infection. See External hemorrhoids, Internal hemorrhoids.

hem·or·rhoids

(hem'ŏr-oydz)

A varicose condition of the external or internal rectal veins causing painful swellings at the anus.
Synonym(s): piles.

[G. haimorrhois, pl. haimorrhoides, veins likely to bleed, fr. haima, blood, + rhoia, a flow]

Medical Dictionary for the Health Professions and Nursing © Farlex 2012

Hemorrhoids

DRG Category:	394
Mean LOS:	4.4 days
Description:	MEDICAL: Other Digestive System Diagnoses With CC
DRG Category:	348
Mean LOS:	5.4 days
Description:	SURGICAL: Anal and Stomal Procedures With CC

Hemorrhoids are a common, generally insignificant swelling and distention of veins in the anorectal region. They become significant when they bleed or cause pain or itching. In the United States, at least 10 million people have hemorrhoids, and up to one-third of these people seek treatment. Hemorrhoids are categorized as either internal or external. Internal hemorrhoids, produced by dilation and enlargement of the superior plexus, cannot be seen because they are above the anal sphincter, whereas external hemorrhoids, produced by dilation and enlargement of the inferior plexus, are below the anal sphincter and are apparent on inspection.

Hemorrhoids develop when increased intra-abdominal pressure produces increased systemic and portal venous pressure, thus causing increased pressure in the anorectal veins. The arterioles in the anorectal area send blood directly to the swollen anorectal veins, further increasing the pressure. Recurrent and repeated increased pressure causes the distended veins to separate from the surrounding smooth muscle and leads to their prolapse (enlarged internal hemorrhoids that actually protrude through the anus).

Causes

Some factors associated with hemorrhoids are occupations that require prolonged sitting or standing; heart failure; anorectal infections; anal intercourse; alcoholism; pregnancy; colorectal cancer; and hepatic disease such as cirrhosis, amoebic abscesses, or hepatitis. Straining because of constipation, diarrhea, coughing, sneezing, or vomiting and loss of muscle tone because of aging, rectal surgery, or episiotomy can also cause hemorrhoids.

Genetic considerations

It is unclear whether familial occurrences of hemorrhoids are related to genetic or environmental factors or a combination of the two. A familial tendency toward weak rectal vein walls and/or valves and varicose veins would increase susceptibility.

Gender, ethnic/racial, and life span considerations

Hemorrhoids are more common in women during late pregnancy and immediately after delivery. Young people who are engaged in heavy weightlifting and exercise are prone to hemorrhoids, and college students who do not eat balanced diets are also at risk. The greatest incidence occurs in adults from 20 to 50 years of age. Men and people with high socioeconomic status are more likely to pursue medical care for the treatment of hemorrhoids than women and people from underresourced communities. In later life, congestive heart failure and obesity contribute to the development of hemorrhoids. There are no known racial or ethnic considerations.

Global health considerations

In Western countries, approximately 4% to 5% of the population is affected with symptoms. This prevalence is likely comparable to most regions around the world.

Assessment

History

Establish a history of anal itching, blood on the toilet tissue after a bowel movement, and anorectal pain or discomfort. Ask if the patient has experienced any mucus discharge. Determine if the patient can feel the external hemorrhoids. Elicit a history of risk factors and dietary patterns.

Physical examination

The most common symptoms are anal itching, anal bleeding after a bowel movement, and anorectal pain. Inspect the patient’s anorectal area, noting external hemorrhoids. Internal hemorrhoids are discovered through digital rectal examination or anoscopy. Note any subcutaneous large, firm lumps in the anal area.

Psychosocial

Patients with hemorrhoids may delay seeking treatment because of embarrassment relating to the location. Provide privacy and foster dignity when interacting with these patients. Inform the patient of every step of the procedure. Provide comfort during examination.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Proctoscopy: Endoscopic examination of rectum and anal canal	Normal rectal lining: Consistently reddish, free of lesions or inflammation	Visualization of internal hemorrhoids	Determines size and location of hemorrhoids

Other Tests: Barium enema, proctoscopic ultrasound, virtual colonoscopy, complete blood count

Primary nursing diagnosis

Diagnosis

Pain (acute or chronic) related to rectal swelling and prolapse

Outcomes

Comfort level; Pain control behavior; Pain level; Symptom severity; Well-being

Interventions

Analgesic administration; Anxiety reduction; Pain management; Medication management; Heat/cold application; Bowel management; Coping enhancement

Planning and implementation

Collaborative

Generally, hemorrhoids can be managed pharmacologically. Conservative treatments include application of cold packs to the anal region, sitz baths for 15 minutes twice a day, and local application of over-the-counter treatments such as witch hazel (Tucks) or dibucaine (Nupercainal) ointment. If conservative treatment does not alleviate symptoms in 3 to 5 days, more invasive management may be needed.

Invasive treatment may be indicated for thrombosis or severe symptoms. Sclerotherapy obliterates the vessels when the physician injects a sclerosing agent into the tissues around the hemorrhoids. With rubber band ligation (RBL), rubber bands are put on the hemorrhoids in an outpatient setting. The banded tissue sloughs. Successive visits may be necessary for many hemorrhoids. Although RBL has a high success rate, it may temporarily increase local pain and cause hemorrhage. In cryosurgery, the physician freezes the hemorrhoid with a probe to produce necrosis. Cryosurgery is used only for first- and second-degree hemorrhoids.

The most effective treatment is hemorrhoidectomy, the surgical removal of hemorrhoids, which is performed in an outpatient setting in 10% of patients. When the patient can resume oral feedings, administer a bulk medication such as psyllium. This medication is given about 1 hour after the evening meal to ensure a daily stool, which dilates the scar tissue and prevents anal stricture from developing. Postoperative care includes checking the dressing for excessive bleeding or drainage. The patient needs to void within the first 24 hours. If prescribed, spread petroleum jelly on the wound site and apply a wet dressing. Complications include urinary retention and hemorrhage. The newest surgical technique for treating hemorrhoids is stapled hemorrhoidectomy. The surgery does not actually remove hemorrhoids but rather the supporting tissue that causes hemorrhoids to prolapse downward.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Docusate sodium (Colace)	100 mg bid PO	Stool softener	Eases defecation
Anusol suppositories	1 bid PR	Analgesic, emollient	Relieve pain and itching
Hydrocortisone ointment or suppositories	Topical or PR as needed for brief courses of therapy	Corticosteroid	Relieve itching and swelling

Other Drugs: Over-the-counter analgesics such as acetaminophen or topical anesthetics such as lidocaine ointment. Some people find that hamamelis water (witch hazel) effectively reduces anal itching. Note: Laxatives are prohibited.

Independent

Most patients can be treated on an outpatient basis. Teach patients and families about over-the-counter local applications for comfort. Explain the importance of promoting regular bowel habits. Emphasize the need for increasing dietary fiber and fluid through a balanced diet high in whole grains, raw vegetables, and fresh fruit. Moderate exercise such as walking can also help regulate bowel function.

Postoperative actions include administering ice packs for pain control and positioning the patient for comfort. After the first 12-hour postoperative period, sitz baths three or four times a day may be instituted to prevent rectoanal spasms and reduce swelling. Explain that the first postoperative bowel movement is painful and may require suitable narcotic intervention for comfort.

Evidence-Based Practice and Health Policy

Lu, L.Y., Zhu, Y., & Sun, Q. (2013). A retrospective analysis of short and long term efficacy of RBL for hemorrhoids. European Review for Medical and Pharmacological Sciences, 17(20), 2827–2830.

RBL is an effective treatment for hemorrhoids, and evidence demonstrates that complications are typically minimal.
Investigators conducted a study in which 254 patients with second-degree and third-degree hemorrhoids (69% and 31% of patients, respectively) were treated with RBL in an outpatient setting. Prior to the procedure, 82.6% of patients presented with rectal bleeding, 38.3% of patients reported constipation, 9.5% of patients reported pruritis, and 3% of patients reported pain.
Postsurgical complications included moderate pain in 41% of patients, severe pain in 1% of patients, bleeding in 2% of patients, and vasovagal symptoms in 1.6% of patients. Two months postprocedure, 92% of the patients with second-degree hemorrhoids and 76% of the patients with third-degree hemorrhoids had no residual symptoms. RBL failed to alleviate hemorrhoids in only 3% of patients.

Documentation guidelines

Physical findings: Rectal examination, urinary retention, bleeding, mucous drainage
Wound healing: Drainage, color, swelling
Pain management: Pain (location, duration, frequency), response to interventions
Postoperative bowel movements: Tolerance for first bowel movement

Discharge and home healthcare guidelines

Teach the patient the importance of a high-fiber diet, increased fluid intake, mild exercise, and regular bowel movements. Be sure the patient schedules a follow-up visit to the physician. Teach the patient which analgesic applications for local pain may be used. If the patient has had surgery, teach her or him to recognize signs of urinary retention, such as bladder distention and hemorrhage, and to contact the physician at their appearance.

Patient discussion about hemorrhoids

Q. What are hemorrhoids?

A. Hemorrhoids are swollen veins in the anal canal. This common problem can be painful, but it’s usually not serious.

Veins can swell inside the anal canal to form internal hemorrhoids. Or they can swell near the opening of the anus to form external hemorrhoids. You can have both types at the same time. The symptoms and treatment depend on which type you have.

Source: WebMD

Q. What are the symptoms of hemorrhoids? My husband complains that when he goes to the bathroom he bleeds. Does this mean he has hemorrhoids?

A. The commonest symptom of internal hemorrhoids is bright red blood in the toilet bowl or on one's feces or toilet paper. However, Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching (pruritus ani), have similar symptoms and are incorrectly referred to as hemorrhoids. If he is also in pain, then go see a Doctor.

Q. How to prevent Hemorrhoids? My brother is suffering from Hemorrhoids. I am very worried about getting them to and want to know how can I prevent them?

A. it's time to change to a healthier diet..one with fibers and vegetables.avoid causes like: Increased straining during bowel movements,portal hypertension, Obesity and Excessive consumption of alcohol or caffeine.

More discussions about hemorrhoids

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