Don’t Sit On It! How to Handle Haemorrhoids

 

One fine day you came back from a vacation, where you have eaten lots of delicious stuffs but neglected fibres and fluids. In the toilet, while performing the daily routine, which has been also neglected during the holidays, you find that the faeces are hard and need more straining than usual. Then there is dripping of blood from the anus and the whole toilet bowl is now stained bright red. You panic and wonder what is happening.

This is an actual incident that one of my patients relayed to me while consulting me on haemorrhoids disease.

Piles is haemorrhoids

What actually are haemorrhoids? The Chinese call it “Ji Cheong”, the Malays call it ‘penyakit buasir’. Some may call it piles as “haemorrhoids” is either difficult to pronounce or spell. They both mean the same.

It is situated inside the anal canal. It is anal cushions of specialised, highly vascular tissue found within the anal canal in the submucousal space. It contains mainly blood vessels and other tissues. If the anal cushions become thickened, enlarged and cause problem – then they are labelled as haemorrhoidal disease.

Facts and figures

The most common questions that I receive from the general public is how common is haemorrhoids in Malaysia and the rest of the world? There is no definite statistic available in Malaysia with regards to its prevalence. This is partly due to the shy Asian nature to mostly keep up with a problem until it becomes severe in term of pain and bleeding. In America, the prevalence rate is about 4.4% – meaning the number of people in a population who has a disease at a given time. Some studies even report that up to 50% of population will experience symptoms of haemorrhoids at some point in their lives.

Don’t just sit on it!

Many patients who have haemorrhoids continue to sit on it and suffer in silence. The symptoms will worsen with time and the disease will become even complicated if nothing is done about it.

The symptoms are mainly bleeding from the anus while defecating and swelling at the anus. If the symptoms persist, the swelling may increase in size and cause severe pain when the swelling cannot be reduced back into the anus. Recurrent bleeding each time while defecating may lead to chronic blood loss leading to anaemia. This may lead to tiredness, dizziness and in severe cases, heart failure.

The cause could be due to prolonged constipation or prolonged straining while defecating. Reduced fibre intake in our modern lifestyle is the main cause of constipation. Prolonged sitting on the toilet bowl could be another risk factor, what’s more, with modern hand-held devises like smartphones, tablets and mobiles holding sway over us. There are no conclusive evidence yet to confirm extended time in the toilet may lead to haemorrhoids but the fact that continued straining while defecating does lead to haemorrhoidal diseases.

Other risk factors that lead to increased intra-abdominal pressure including pregnancy, chronic cough and carrying weight (in body building) may contribute to haemorrhoids to some extent.

Types of haemorrhoids

There are two types of haemorrhoids – the external haemorrhoids and internal haemorrhoids. As the name suggests, the internal is located within the anal canal and the external one is one that is visible; can be seen and felt. The extent of the disease can be classified into four degrees.

The 1st degree – bulge into the lumen of anal canal, plus minus bleeding

The 2nd degree – protrusion at time of bowel movement and reduces spontaneously

The 3rd degree – protrude spontaneously or during bowel movement, requires manual replacement

The 4th degree – permanently prolapsed and irreducible

Haemorrhoid treatments

To confirm whether the patient has indeed per rectal bleeding due to haemorrhoids, the doctor will take a detail history of the symptoms, duration and any other related disease. The patient will be examined clinically with digital rectal examinations followed by a proctoscopy to confirm the presence of haemorrhoids.

The treatment of haemorrhoids depends on the condition and severity of the disease. For the milder case of per rectal bleeding, the patient could be advised with medical treatment in the form of stool softener, laxative, higher fibre intake in the diet and avoid straining too much while defecating.

If the haemorrhoids are in grade 2 and 3, the best treatment is through surgical intervention. There are many type of treatment for haemorrhoids. It all depends on the degree of the haemorrhoids.

As out-patient setting (whereby the patient can go home after the treatment) rubber banding ligation of the haemorrhoids can be done without much complication. The other option is Injection sclerotherapy.

For more severe case as in 2nd, 3rd and 4th degree haemorrhoids, surgical treatment is a better option. It offers better cure and less recurrence. The patient needs to be admitted to the hospital and the procedure is carried out under anaesthesia. The methods include:

Open surgery – Milligan-Morgan open haemorrhoidectomy or closed Ferguson Haemorrhoidectomy

This is mainly for the grade 4 haemorrhoids whereby the haemorrhoids has prolapsed and thrombosed.

Stapler haemorrhoidopexy with surgical stapler – i.e. PPH circular stapler or EEA stapler.

This is meant for prolapsed grade 3 haemorrhoids. It has the advantage of less post-operative pain and faster recovery time.

LASER haemorrhoidoplasty

It is a latest procedure available now. It has the advantages of being least invasive, less pain and faster recovery. The haemorrhoidal tissue is ablated with the LASER therapy.

Radiofrequency ablation of haemorrhoids

It employs similar technique as LASER haemorrhoidoplasty. Instead of LASER as the energy source, it uses radiofrequency. It has similar advantages to LASER haemorrhoids.

One important advice for patients is that not all cases of bleeding while defecating is caused by haemorrhoids. It may be due to anal canal cancer or rectal cancer which can have similar symptoms of per rectal bleeding. It is always safer to consult a doctor to confirm the diagnosis rather than self-diagnose and self-treat (which is becoming more common nowadays).

Which treatment is the best?

All have their pros and cons. Each patient and the degree of haemorrhoids are different. It is best to let the specialist to have a detailed examination, confirm the disease and then offer the best suitable treatment for the patients.