Haemorrhoid

Symptoms and causes

What is it?

Haemorrhoids are blood-filled swollen veins located at the end of the rectum, near the anus. This spongy network of fine blood vessels is covered with a thin layer of mucous membrane. When these blood vessels fill up with blood, they help the sphincter muscle to seal the anus. In this way, they offer extra protection against unwanted loss of gas or mucus. So, in normal circumstances, haemorrhoids are certainly useful.

Symptoms appear when the haemorrhoids swell excessively, which is sometimes called 'piles'.

Causes

This excessive swelling is usually caused by our diet. Dietary fibres retain extra moisture and thus cause a soft stool. Low-fibre food therefore often gives rise to dry and hard stools, which means that extra pressure has to be applied during bowel movements. This pressing causes overpressure on the weaker swollen veins, leading to irritation and abnormal expansion. These swollen haemorrhoids make bowl movements even more difficult, which means that patients have to squeeze even harder. This creates a vicious circle.

Many women also suffer from haemorrhoids during pregnancy. This nuisance is caused by an increased pressure in the abdomen, the softening of the tissues towards the end of pregnancy and pressing during childbirth.

Some patients appear to have a familial predisposition, where hereditary factors may play a role.

Symptoms

By pressing, the swollen haemorrhoids can be pushed out. They sink through the sphincter and emerge from the anus. Because of this, many people get a dull pain or a feeling of pressure in the anus. In the beginning, the sagging haemorrhoids will automatically retreat inside again, but after a while this will no longer happen and they will have to be pushed back inside.
When the mucous membrane on top of the dilated swollen veins becomes irritated or damaged, mucous or blood loss on the toilet paper may become visible. Because the sagging haemorrhoids hamper a hermetic closure of the anus, there may also be loss of moisture or mucus . This in turn leads to irritation of the skin around the anus, resulting in itching and/or burning.
If the haemorrhoids continue to increase, a visible swelling may occur. It can cause pain when pushing or even through the formation of a clot. The swelling sometimes also makes it difficult to clean after a bowel movement, which gives hygiene problems.
When the haemorrhoid tears a little bit during the bowel movement, there can be considerable clear red blood loss. In chronic situations, this can even lead to anaemia.
In case of thrombosis (clot formation) in a haemorrhoid, the pain can become very severe. Sometimes patients show up at the A&E because of this.
- If the clot exists for less than 48 hours, it can sometimes be removed at the A&E. This is done via a small incision under local anaesthetic. Afterwards, this wound can bleed for another two days.
- If the clot has been present for more than 48 hours, a watchful waiting approach is preferable. The clot will usually disappear completely after a few weeks through the use of painkillers and anticoagulant medication/anesthesia.
External haemorrhoids sometimes give rise to the formation of marisks or 'skin flaps' due to stretching of the skin. These flaps are painless but can interfere with post bowel movement cleaning, causing hygienic problems. Sometimes they also cause itching or irritation.

Diagnosis and treatment

Diagnosis

In the event of persistent symptoms, further medical examinations are appropriate. Depending on the type of symptoms, it may be decided to perform further technical examinations:

The physician will start with an inspection of the anus, possibly followed by an internal examination with the finger.
Sometimes it is useful to get a picture of the inside of the rectum. This can be done using a short camera which is inserted in the anus, the proctoscope. That examination is not painful, but does require an uncomfortable position (leaning on knees and elbows). No special preparation is required for this.
Red blood loss through the anus can also be caused by abnormalities in the colon. In this case, it may be useful to perform an internal examination of the intestine by endoscopy (colonoscopy). Particularly if the blood loss is accompanied by a change in the bowel movement pattern or if you are over 50 years of age, this examination may be recommended.
An intestinal examination. This examination requires a specific intestinal preparation. The practical details will be explained to you by the gastroenterologists at the outpatient clinic.

General measures

Specific lifestyle changes can reduce the seriousness of haemorrhoids' swelling and thus reduce or even eliminate the symptoms.

Promote a soft stool: eat high-fibre food (vegetables, fruit, wheat bread...) and drink plenty of water. It is even possible to add extra fibre to the diet.
Limit amounts of coffee and tea: these cause anal irritation and lead to itching and rashes. Spicy food and alcohol are also best avoided.
Try not to postpone the urge to go for too long when you feel the stimulation. This leads to hardening of the stool and a more difficult bowl movement afterwards. A certain regularity is therefore the solution.
Try to avoid pressing. Also sitting on the toilet for a long period of time (for example, to read) is not recommended.
Try to move sufficiently. Avoid being overweight.
In case of persistent symptoms, certain ointments can offer some relief. Sometimes, it also makes sense to use inflammatory medication (venotonics). In case of severe constipation, sometimes laxatives are indicated. Discuss this first with your GP.
Ensure good hygiene by cleaning the anus with lukewarm water after a bowl movement and drying it well. The use of soap or perfumed toilet paper is not recommended as these can exacerbate itching and irritation.

Treatment

If the haemorrhoids continue to cause discomfort despite these general lifestyle rules, other measures are appropriate. There are various techniques for treating symptomatic haemorrhoids. Depending on the specific situation, the most appropriate technique will be chosen.

Non-surgical procedures

In the first instance, it is advisable for every patient with haemorrhoids to follow the lifestyle rules described above. In some cases, these measures can clearly reduce the symptoms or even eliminate them altogether. If the haemorrhoids nevertheless continue to cause discomfort, other measures are appropriate.

There are three different non-surgical techniques for treating symptomatic haemorrhoids:

Infrared treatment or injection of haemorrhoids
Rubber band ligation
Removing skin tags or ‘marisks’

You can read more about these different non-surgical procedures here.

Surgical procedures

If the haemorrhoids do not or insufficiently respond to the above treatments, a more drastic treatment may be necessary. There are various options for this as well. A choice is made among various techniques based on the type of haemorrhoids, the type of symptoms and some patient-specific characteristics: