Hemorrhoids – Causes, Risk Factors, Symptoms, Complications And Diagnosis
Hemorrhoids are varicose dilatations of the veins located in the wall of the anus and rectum. Veins of the anus and rectum have protective role, to help a perfect closure of the rectum. When exercising pressure on them, these vessels begin to dilate. Hemorrhoids are very common both in men and women, about half of people aged over 50 have hemorrhoids.
Rectal veins in submucosa form a rich network, known as hemorrhoidal plexus. The hemorrhoidal plexus is divided into two parts: internal and external hemorrhoids hence the hemorrhoids division into two types:
- Internal Hemorrhoids. Internal hemorrhoids are hemorrhoids that are inside the rectum above the anus. Internal hemorrhoids can not be seen with the naked eye and are covered with digestive lining that is not sensitive, so there is no pain.
- External hemorrhoids. External hemorrhoids are formed under the skin of the anus. External hemorrhoids may be feelt (appearing as a small prominence under the skin of the anus) and pain is present due to the distension of the skin that is rich in sensory nerves.
Hemorrhoids occur when pressure increases in the veins around the anus and rectum. Factors that increase pressure in the hemorrhoidal plexus include:
- Gastrointestinal disorders (chronic constipation, diarrhea, etc.). Increased effort during defecation is considered the most common cause of hemorrhoids. This occurs frequently in patients with chronic constipation. Long periods of time spent on the toilet causes increased pressure in the veins of the rectal canal.
- Pregnancy and childbirth. Both pressure fetus in the abdomen and hormonal changes leads to enlargement of hemorrhoidal vessels. These vessels are subject to severe pressure during childbirth. For most women, hemorrhoids that occur after pregnancy are a temporary problem.
- Lifting heavy objects can cause increases in pressure in the hemorrhoidal plexus similar to those caused by constipation. Lifting weights is known as a hemorrhoids aggravating factor and is often associated with their formation.
- Poor diet, especially rich in meat and nourishing food without eating fruits and vegetables or foods that contain fiber (bran, yogurt, vegetables, etc.). The role of fiber is to stretch the gut (if you drink enough fluids) and to boost the volume bowel movements (peristalsis), easing digestion and maintaining normal activity of intestinal cells, favoring the absorption of nutrients and thus preventing constipation. Diets rich in spices favors hemorrhoids.
- Liver disease. Cirrhosis increases the pressure in the portal circulation whose expression is symptomatic hemorrhoids.
- Pelvic tumors, genital or rectal can compress the hemorrhoidal plexus drainage ways, and sometimes rectal wall itself.
- Extended sitting or standing
- Chronic Cough
- Chronic heart failure cause venous stasis in the lower hollow system.
- Excessive use of laxatives or enemas
- Excess alcohol, coffee, chocolate, caffeinated beverages consumption,
- Anal sex
Patients who have family members with hemorrhoids are more likely to develop hemorrhoids. In hemorrhoids there is a hereditary predisposition related to a lower quality of collagen, which leads to impaired venous walls.
Hemorrhoids symptoms include:
- Anal bleeding with “fresh blood”, bright red, in small quantities discovered in the stool, or on the toilet paper.
- Itching or irritation in the anal region
- Pain or discomfort in the anal region
- Swelling around the anus
- Elimination of mucus in the stool
- The appearance of stains on underwear due to mucous secretions.
External hemorrhoids may remain without symptoms: they do not bleed, are not painful and do not prevent defecation. They are seen during inspection as painless growths of soft consistency that from around the anus. Hemorrhoids are getting worse when coughing or during defecation effort.
The dominating symptom of internal hemorrhoids is bleeding, mucous discharge, pruritus (itching) and pain. Small quantities of blood losses, but repeated ,characteristic to hemorrhoids can produce anemia (the patient is pale and accuses tiredness). Due to continuous flow of these secretions and anal region irritation pruritus occurs (itching). Typically, patients with hemorrhoids do not cause pain, but the patient is complaining about the feeling of weight and incomplete evacuation after defecation. The occurrence of pain in patients with hemorrhoids in the anal region is associated with complications, especially inflammatory complications
- Anal fissure (a tear in the mucous lining of the lower rectum that causes pain and bleeding during important bowel movements .
- Anal abscess (a collection of pus in the perianal region and also a medical emergency)
- Perianal fistula is a communication between the anal canal and perianal skin.
- Prolapsing, (internal hemorrhoids that reach the outside, followed by their swelling and difficult transition back, causing discomfort and pain)
- Thrombosis and inflammation. Hemorrhoid formation becomes painful and defecation is painful. Hemorrhoids appear as shiny purplish growths, turgid, very sensitive to touch. After 3-4 days, symptoms are relieved by breaking a small thrombosed nodule with bleeding and elimination of thrombus.
- Strangulation of internal hemorrhoids
The diagnosis of hemorrhoids is established after carrying the patient medical history and physical examination. The patient is generally asked about bowel habits, including frequency and any recent changes, and certain symptoms such as pain, bleeding or itching in the anal region. Physical examination usually involves a digital rectal examination. For digital rectal examination the doctor will use disposable non-sterile surgical gloves, the index will be lubricated so that the maneuver will be as little annoying as possible. During the digital rectal examination doctor feels the hemorrhoids and highlights laxity (slip lining).
This examination means using a instrument as a short thin tube equipped with lighting to analyze the anal canal (the last centimeters).
Rectoscopy is an exam that allows visual exploration of the rectum wall. A Rectoscope involves inserting through the anus into the rectum a rigid endoscope called rectoscope (a tube with a length of 25 centimeters and 1.5 centimeters in diameter, equipped with an optical system). Biopsies are possible (removal of rectal tissue). Rectoscopy is useful to diagnose internal hemorrhoids.
This allows the doctor to observe a third area located in the lower colon (sigmoid colon). This exam is done using a thin tube, flexible, with a small camera is inserted all the way easily into the rectum and then moved easily through the intestine. During a sigmoidoscopy samples can be harvested (biopsy) for examination under a micorscope.
Other diagnostic tests, including blood tests and analysis of faeces can be used to exclude other possible causes of symptoms.