Why do you need this hemorrhoid?
Hemorrhoids
A.I.Parfenov, MD, Professor, Central Research Institute of Gastroenterology, Moscow
Journal "Medical Council" No. 9-10 (2010)
Published on the website "Remedium"Hemorrhoids – hypertrophy of the cavernous veins of the rectal plexus of the rectum – is the most common proctological disease and is manifested by pain, bleeding from the rectum.
The term "hemorrhoids" means bleeding. Since ancient times, diseases of the rectal veins have been called, the most typical manifestation of which is varicose veins of the rectal plexus and the outflow of blood from the rectum.
Hemorrhoids are equally common in middle-aged and elderly men and women. The prevalence of hemorrhoids is approximately 120 cases per 1000 adults, which allows it to be considered the most common disease. Among proctological diseases, hemorrhoids account for from 34 to 41%.
Factors such as sedentary lifestyle, pregnancy and childbirth, prolonged constipation, heavy physical work associated with lifting weights, the habit of eating spicy and spicy food, diseases of the pelvic organs that cause compression of the diverting veins, as well as the absence of valves in the diverting veins of the rectal plexus predispose to the disease.
Hemodynamic and muscular-dystrophic factors play a leading role in the pathogenesis of hemorrhoids. The basis of hemodynamic disorders is the excess of arterial blood flow over venous outflow through the cavernous veins. As a result, the latter increase, which leads to the formation of nodes. Of great importance is the dystrophy of the longitudinal muscle of the submucosal base of the rectum and the Parks ligament located in the intersphincter space of the anal canal. These structures form the fibrous-muscular framework of internal hemorrhoids and hold them in the anal canal above the anorectal line. Under the influence of the above adverse factors, there is an increase in the size of hemorrhoids, their displacement in the distal direction, and eventually loss from the anal canal.
Hemorrhoids can be primary and secondary. The occurrence of primary hemorrhoids is explained by an innate predisposition. The cause of secondary hemorrhoids is a violation of the outflow of blood from the rectal venous plexuses with portal hypertension, stagnation in the inferior vena cava, heart failure, prolonged constipation, sedentary lifestyle, heavy physical work.
There are external and internal hemorrhoids. With external hemorrhoids, the veins of the external rectal plexus, lying under the skin around the anus, expand. As a result, hemorrhoids are formed, which in the form of skin folds (fringes) hang from the outside along the edge of the anal ring. Such nodes can increase and take the form of large petals. Swelling, they create inconvenience when walking, can cause irritation of the skin of the anus, maceration and itching.
In addition, external hemorrhoids (especially if they are located along the posterior semicircle of the anus) often contribute to the formation of cracks. Usually, the crack begins at the base of the node and, as a rule, does not respond to conservative treatment.
With external hemorrhoids, acute thrombophlebitis of the hemorrhoid node may develop. At the same time, a rounded dense formation in the shape of a hazelnut appears in the anus (Fig. 1). Acute pain lasts 7-10 days, then gradually subsides. However, the seal (thrombus) sometimes remains for a long time.
Figure 1.
Anoscopy. Acute thrombophlebitis of the hemorrhoid node
With internal hemorrhoids, varicose veins of the rectal plexus occur, which is located under the mucous membrane of the lowest part of the rectum above the anal-cutaneous line.
Internal hemorrhoids, if they do not fall out of the anus, can be detected only by conducting a special examination of the rectum. As a rule, they have a rounded or fusiform shape, a wide base, are covered with a smooth mucous membrane and are emptied when squeezed with a finger (Fig. 2).
Figure 2.
Anoscopy. Internal hemorrhoids
Only in relatively rare (neglected) cases, hemorrhoids have a finely rounded surface, resembling a mulberry or raspberry in appearance. Internal hemorrhoids, even with pronounced expansion, are painless, pain appears only when they are pinched and infected. External hemorrhoids are more often painful, since there are nerve endings in the area of their formation.
In the elderly, the veins of the internal rectal plexus are almost always varicose. However, such an age-related feature is not yet hemorrhoids and only demonstrates a clear predisposition to its development.
The main symptoms of hemorrhoids are: bleeding from the rectum during defecation (51%), nodes falling out through the anus (37%), itching and discomfort in the anus (5-7%), pain and intermittent inflammation with swelling of the nodes, their thrombosis, and sometimes gangrene.
Bleeding during defecation is the most typical and frequent sign of hemorrhoids. It mainly originates from internal hemorrhoids. The amount of blood released during defecation can vary widely – from poor staining of toilet paper to copious blood loss, sometimes requiring urgent blood transfusion. Usually the blood has a bright red color, but occasionally it can be purple and even dark (if it accumulates in the intestine before defecation begins).
The release of dark blood in the form of clots may occur at the very beginning of defecation. Some patients note that bleeding during defecation occurs in the form of a splashing jet (which is typical for internal hemorrhoids).
Bleeding during defecation is the most typical and frequent sign of hemorrhoids.
Hemorrhoids can occur chronically or in the form of an acute attack. Acute hemorrhoids develop with thrombosis of hemorrhoids, after which an inflammatory process develops in the node and surrounding tissues.
The clinical course of acute hemorrhoids has three stages (Vorobyev G.I. et al., 2001):
- Thrombosis of external and internal hemorrhoids without an inflammatory process.
- Thrombosis complicated by inflammation of hemorrhoids.
- Thrombosis of hemorrhoids complicated by inflammation of subcutaneous tissue and perianal skin.
With an exacerbation of hemorrhoids, internal nodes are primarily affected, and external nodes are involved in the process due to the spread of inflammatory infiltration to the anus. Isolated inflammation of individual external hemorrhoids is much less common. At the same time, in the area of one of the external nodes, a rounded or oval thrombus can be observed, which is very painful when pressed.
An attack of exacerbation of hemorrhoids is characterized by sharp pain during defecation, walking, and sometimes even with minor movements. Some patients suffer so much from pain that they have to take painkillers. Intense pain in the anus indicates infringement of hemorrhoids, complication with thrombosis or the appearance of an anal fissure.
Inflammation of internal hemorrhoids is usually accompanied by a vivid clinical picture. The hemorrhoids that have fallen out swell, increase, and therefore the anal canal expands, and the anus gapes. The patient is worried about a strong throbbing pain. Body temperature may rise and chills may appear. External hemorrhoids themselves rarely become inflamed, but they are almost always involved in the process of inflammation of internal nodes.
The loss of internal nodes occurs quite often. They can fall out during bowel movements and be set on their own or with the help of a finger. In the future, the loss of nodes occurs even with light straining. It should be noted that the loss of nodes is often accompanied by relaxation of the tone of the external sphincter. Then the reason for the loss of nodes is already its relaxation. The subsequent violation of the tone of the external pulp leads to the fact that the nodes begin to fall out at the slightest physical exertion, even when walking.
The appearance of complaints of pain during and after defecation with internal bleeding hemorrhoids suggests the presence of a crack in the anus.
Most patients have a long history of the disease – up to 20 years or more. Patients who are aware of the nature of their ailment are not very concerned about intermittent bleeding. Only in cases of heavy blood loss or frequent exacerbations of the disease, they agree to the operation.
Depending on the degree of enlargement of nodes and accompanying symptoms, Zh.M.Yukhvidova (1984) identified the following stages of hemorrhoids.
Stage I – the nodes slightly rise above the mucous membrane of the rectum, disappear when pressed (Fig. 3). During defecation, the node may fall out of the anus, but it is spontaneously adjusted. Pain is usually absent, but bleeding is possible.
Figure 3.
Anoscopy. Hemorrhoids, stage I
Stage II – hemorrhoids fall out after each act of defecation, they have to be adjusted by hand. Nodes are often injured, inflamed, sometimes necrotised (Fig. 4). Recurrent pain, decreased tone of the anus sphincter are characteristic.
Figure 4.
Anoscopy. Hemorrhoids, stage II
Stage III hemorrhoids are characterized by a large size of nodes and the impossibility of their independent reduction in case of prolapse (Fig. 5). They appear when coughing, straining, sneezing. Nodes gradually undergo fibrous changes, often bleed.
Figure 5. Anoscopy.
Hemorrhoids, anal prolapse, stage III
The diagnosis is established on the basis of a proctological examination using a rectal mirror and a rectoscope. One finger examination is not enough, since uncomplicated internal hemorrhoids are not palpated. It is necessary to find out the possible connection of hemorrhoids with the underlying disease, simultaneously assessing the state of the cardiovascular system and liver.
The cause of any intestinal bleeding should be determined by instrumental examination. Only after the exclusion of polyps, cancer, ulcerative colitis and other colon diseases in the patient, the doctor has the right to associate the cause of rectal bleeding with the identified hemorrhoids. For cancer of the rectum, sigmoid colon, it is more typical to secrete dirty bloody mucus or dark clots both before defecation and mixed with feces. Given that rectal and colon cancer is quite common, in all cases of bleeding from the rectum, it is necessary to conduct a detailed finger examination, colonoscopy or X-ray examination of the colon (irrigoscopy).
In the case of dormant external hemorrhoids, differential diagnosis is performed with prolapse of the mucous membrane of the anus and rectum. Sometimes a hemorrhoid node can look like a polyp.
Treatment
Uncomplicated hemorrhoids. The initial stages of chronic hemorrhoids and the acute course of the disease are indications for conservative treatment.
Local treatment should be aimed at eliminating pain associated with thrombosis or inflammation of hemorrhoids, and bleeding. To do this, phlebotropic drugs are used to improve vein tone and microcirculation in the cavernous corpuscles. Detralex gives a good effect. According to the observations of G.I.Vorobyov et al. (2001), treatment with this drug can reduce the duration of exacerbations by more than 2 times and reduce the severity of exacerbations by 1.5 times.
Pain in hemorrhoids is more often associated with the infringement of a thrombosed hemorrhoid node or the appearance of an acute anal fissure.
In acute inflammation of hemorrhoids, treatment is carried out according to the following scheme. It is necessary to observe strict bed rest for 7-14 days. It is advisable to delay the stool for 4-5 days. To do this, with a tendency to constipation, it is enough to prescribe a slagless diet: protein omelet, beef broth, boiled meat turned through a meat grinder, slimy rice or longitudinal porridge (on water with a small piece of butter), white crackers (3-4 crackers a day) and copious drinking (4-6 glasses of barely sweetened tea).
Pain in hemorrhoids is more often associated with the infringement of a thrombosed hemorrhoid node or with the appearance of an acute anal fissure.
In the first 2 days, cold lotions from a weak solution of potassium permanganate are applied to the site of inflamed nodes. Cotton swabs soaked in this solution are applied to inflamed nodes every 15 minutes for 1.5–2 hours (3-4 sessions per day). To eliminate inflammation, nonsteroidal anti-inflammatory drugs (diclofenac, ketoprofen, etc.) are prescribed. A wide compress with Vishnevsky ointment is applied to the area of the anus and inflamed nodes, which is left for 2 days. Starting from 4-5 days, daily baths with potassium permanganate (34 ° C), candles and compresses with Vishnevsky ointment are made.
Suppositories with local analgesic and anti-inflammatory effect (Ultraprokt, Intendis) are shown to eliminate pain. Depending on the localization of the disease, various forms of Ultraprokt are used. Suppositories are used for localization of the process directly in the rectum: internal hemorrhoids and proctitis. With external hemorrhoids, superficial cracks of the anus, anal itching, perianal neurodermatitis, Ultraprokt ointment can be used perianally. For anal use, there is a special nozzle with an applicator. Unlike a number of other drugs, Ultraprokt has both a rapid effect, quickly eliminating unpleasant symptoms, and a persistent long-term effect, thereby providing relief of symptoms for a long time.
Thanks to this combination, Ultraprokt is very convenient to use – candles 1 time a day, ointment 2 times a day, which increases mutual understanding between the patient and the doctor. The second component is cinchocaine, a local anesthetic specially created for the epithelium of the anus. At the same time, unlike drugs containing other anesthetics, cinchocaine is practically not absorbed into the systemic circulation, thereby the risk of side effects is minimal.
Such a combination allows you to get a pronounced anti-inflammatory, antipruritic and analgesic effect. The drug can be used by everyone, with the exception of children under 4 years of age and in the first trimester of pregnancy, for whom, in principle, acute problems with the rectum are not characteristic. The presence of two dosage forms of Ultraprokt allows you to choose exactly the form of the drug that is suitable for the patient.
It is extremely important to monitor the work of the intestines. If the act of defecation is accompanied by some straining, it is necessary to recommend that the patient take a teaspoon of lactulose (dufalac), vaseline oil before going to bed. In cases of persistent constipation, a cleansing enema should be resorted to. It should be remembered that the tip of the enema, liberally lubricated with vaseline, should be carried into the anal canal along the healthy wall of the anal opening, so as not to touch a dense painful knot. A cleansing enema in these cases has certain advantages over laxatives, as it promotes relaxation of the sphincter and better intestinal cleansing.
Hemorrhoidal bleeding. Continuous bleeding for 1 hour is a sign of an acute process. To eliminate it, you can use candles containing adrenaline. In addition, G.I.Vorobyov et al. (2001) recommend local hemostatic agents consisting of fibrinogen and thrombin. When injected into the anus, they dissolve, forming a fibrin film. Candles are injected 2 times a day (at night and after a stool). Inside, a 10% solution of calcium chloride is prescribed (1 tbsp. l. 4-5 times a day).
Minimally invasive methods of hemorrhoid treatment. A typical hemorrhoidectomy is currently performed relatively rarely. Minimally invasive methods of treatment are mainly used (sclerotherapy, infrared photocoagulation of hemorrhoids, ligation with latex rings, electrocoagulation, etc.).
Acute thrombophlebitis of hemorrhoidal veins. In acute thrombophlebitis of the hemorrhoid node, therapeutic measures should be aimed at resorption of the thrombus. During the first 3-4 days of the disease, the patient must observe bed rest. The food should not be irritating. It is necessary to completely exclude alcohol.
With thrombosis of hemorrhoids, anticoagulants of local action are prescribed: hepatrombin G, nigepan, levosin, levomekol. Hepatrombin G, consisting of heparin, prednisone and the anesthetic polydocanol, has proved particularly well. According to the observations of G.I.Vorobyov et al. (2001), polydocanol has a local anesthetic effect similar to lidocaine, but less often causes allergic reactions.
Thrombosis of hemorrhoids is often complicated by their inflammation with the transition to subcutaneous tissue and the perianal region. In these cases, water-soluble ointments with anti-inflammatory properties (levosin, levomekol) are additionally prescribed. For resorption of the thrombus, sedentary warm (34-35 C) baths with potassium permanganate lasting 10-15 minutes are prescribed. If there is no effect, surgical treatment is recommended.
External hemorrhoids that do not cause maceration, itching, wetness and are not accompanied by inflammation and thrombosis do not require special treatment. To prevent complications, it is recommended to carry out a thorough toilet after a stool and regularly make baths with potassium permanganate.
In the case when the nodes reach a large size, often become inflamed or cause itching and maceration, their excision is shown. Surgical treatment is also indicated if hemorrhoids are complicated by a crack in the anus.
Forecast
The prognosis of the disease depends on the timeliness of surgical treatment. After ligation of nodes and hemorrhoidectomy, some patients experience temporary, gradually disappearing anal incontinence after treatment.
Prevention
In order to avoid the development of hemorrhoids, it is necessary to carry out preventive measures. Often parents teach the child to sit on the pot for hours, which leads to increased blood filling of the rectum and creates prerequisites for the formation of hemorrhoids. Therefore, since childhood, it is necessary to educate the child's reflex to a chair at the same hours and to ensure that the act of defecation is carried out as quickly as possible.
Diet is of great importance for the prevention of hemorrhoids and its complications. The patient should be warned about the dangers of even minor abuse of alcoholic beverages and spicy food. Sometimes it is enough to exclude even the lightest alcoholic beverages and spicy dishes from the diet in order to practically cure the disease. If the patient does not follow these recommendations, the hemorrhoids will progress, despite the treatment.
An important component of hemorrhoid prevention is the prevention of constipation by consuming hydrophilic colloids (dietary fiber) and a sufficient amount of fluid. To do this, wheat bran, seaweed and flaxseed are used in their natural form or in the form of medicines with high water retention capacity. Regulation of the consistency of intestinal contents and its transit through the colon is an indispensable condition not only for the prevention, but also for the successful treatment of hemorrhoids.
An important component of hemorrhoid prevention is the prevention of constipation by consuming hydrophilic colloids (dietary fiber) and a sufficient amount of fluid.
When working with prolonged sitting, it is recommended to do gymnastics 2-3 times a day for 5-7 minutes. To prevent hemorrhoids , there is the following complex of effective gymnastic exercises:
1) walking with a high lift of the legs bent at the knees;
2) swing movements alternately with the right and left foot forward, backward and to the side;
3) leaning to the sides (legs shoulder-width apart, arms along the trunk);
4) tension of the buttocks with simultaneous retraction of the anus (hands on the belt, heels and socks together);
5) squat on your toes with your knees wide apart.
Finish the complex by repeating the first exercise.
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