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Naturopathy Digest, 9/06 - Hemorrhoids:
The Disease No One Talks About
by Dr. Steven Cranford
"The Lord will smite thee with the botch of Egypt and with
the 'emerods.'
- Deut 28:27 KJV
I quote the above Old Testament scripture to confirm the historical
verification of "emerods" or hemorrhoidal disease. This supports
that this dreaded condition has been upon this planet for centuries
and is not necessarily a disease of this "new age."
It's a fact that 50 percent of the adult
population over the age of 50 has some degree
of hemorrhoidal formation. Approximately
5 percent of the general population has symptoms
of hemorrhoids and 80 percent of both sexes
will have the symptoms at some time in their
lives.
What Are Hemorrhoids?
Hemorrhoids can be defined in a couple of
different ways. The "not-so-clinical definition" is
that they merely are varicose veins located
in the anorectum. I must admit this definition
allows the physician to explain the condition
more easily for the patient; however, it
is an oversimplification. A more recent study
has described the presence in the anal canal/lower
rectum of specialized, highly vascular "cushions" or "pads" consisting
of discrete masses of thick submucosa which
contain blood vessels, smooth muscle, and
elastic and connective tissue. It is suggested
that hemorrhoids are nothing more than the
sliding downward of this part of the anal
canal lining. Such cushions are present in
everyone, and it's suggested that the term "hemorrhoids" be
confined to situations in which these cushions
are abnormal (e.g., enlarged, inflamed) and
cause symptoms. The cushions or pads are
located in three constant sites: right anterior,
right posterior and left lateral; and upon
examination, the physician will see the presence
of hemorrhoidal disease. This also is called
the "surgical Y."
How Common Are Hemorrhoids?
It's a well-known fact that 50 percent of
the adult population over the age of 50 has
some degree of hemorrhoidal formation. Approximately
5 percent of the general population has symptoms
of hemorrhoids (bleeding, pain, itching,
protrusion). When I teach, I use the example
of being at a Portland Trail Blazer basketball
game with 20,000 people in attendance; 1,000
of those likely will have symptoms related
to hemorrhoidal disease. Eighty percent of
both sexes will have the symptoms of hemorrhoids
at some time in their lives.
What Causes Hemorrhoids?
Anything that increases the pressure within
the hemorrhoidal venous plexus eventually
can lead to the formation of hemorrhoids/prolapsus.
You also must remember that the prevalence
of this disease is highest in countries with
the most affluence. This probably is due
to the existence of fiber-depleted diets,
leading to constipation and more pressure
during the defecatory act on the surrounding
venous plexus in the anorectum. Another interesting
consideration is the absence of one-way leaflet
valves in the veins of the portal system;
thus, any increase in pressure within the
portal venous system (liver disease, obesity,
etc.) eventually will cause an increase in
the venous pressure within the pelvic internal
hemorrhoidal venous plexus. This result is
related directly to the swelling of the anal
cushions/pads and hemorrhoid formation. One
factor that also must be considered is the
amount of pressure within the internal sphincter
muscle. This smooth muscle has receptors,
which are sensitive to a variety of chemicals;
thus, when a chemical stimulates the alpha-receptors
of the internal sphincter muscle, contraction
occurs, causing a narrowing of the anal canal
and/or an overshoot of this muscle when stimulated
during the act of defecation. This would
explain why the Lord technique, or intense
anal dilation, would be a viable treatment
for hemorrhoidal disease. Other factors to
consider are the fact that we are upright
and biped, and that gravity causes increased
intrarectal venous pressure.
Classification of Hemorrhoids
The following allows the proctologist to
establish a baseline for the purpose of discussion
of this disease with a nomenclature that
is consistent.
Internal hemorrhoids: symptomatic,
exaggerated submucosal vascular tissue located
above the anorectal line and covered by transitional
and columnar (mucosal) epithelium.
- 1st degree: no protrusion, but may bulge
into the anal canal; may bleed.
- 2nd degree: protrudes at the time of
BM, but reduces spontaneously; may bleed.
- 3rd degree: protrudes at the time of
BM; must be manually reduced; may bleed.
- 4th degree: permanent prolapse/protrusion
and cannot be reduced; may bleed.
External hemorrhoids: dilated venules
of the inferior hemorrhoidal venous plexus
located below the anorectal line and covered
by squamous/modified squamous epithelium.
There are two different types of external
hemorrhoids: non-thrombosed (dilated venules,
which do not contain blood clots) and thrombosed
(external hemorrhoids containing blood clots
of different sizes, whose symptoms will be
determined by the size of said clots; these
lesions are very painful and usually appear
suddenly, whose duration and severity are
determined by their size).
Mixed hemorrhoids: a combination
of both internal and external hemorrhoids.
Clinically, these are hemorrhoids that usually
occur in the confines of the anal canal and
are covered by modified stratified squamous
epithelium.
Strangulated hemorrhoids: a combination
of both internal and external hemorrhoids;
characterized by mucosal and anal prolapsus,
intense spasms of the internal and external
sphincter muscle group, cutting off the blood
supply; usually contains multiple blood clots.
Because of the vascular abnormality due to
the muscle spasm and if allowed to progress,
this type of hemorrhoidal disease can become
necrotic and gangrenous.
Signs/Symptoms of Hemorrhoidal Disease
Bleeding. Seventy-five
percent of all bleeding from the large bowel
is caused by hemorrhoidal disease. Bleeding
associated with hemorrhoids will be bright
red and the amount will be dependent upon
the severity of this condition. Anemia is
not uncommon and at times hospitalization
is necessary due to blood loss.
Pain. One must recall the
anatomy of the anorectum when interpreting
pain patterns consistent with hemorrhoids.
Internal hemorrhoids usually are not painful
unless strangulated. When there is pain involved
with hemorrhoids, it is indicative that the
condition originates at or below the anorectal
line, therefore being consistent with mixed
or external hemorrhoidal disease.
Protrusion/Prolapse. If
the hemorrhoidal disease has progressed,
there is frequently protrusion, which is
most noticeable during defecation. If the
protrusion is constant (4th degree hemorrhoids)
mucosal leakage and fecal soiling are more
common (wet anus syndrome). This frequently
causes persistent pruritus/itching as a common
symptom.
Diagnosis of Hemorrhoids
Care history: Usually a patient
will have a rich history of this condition,
dating back for years prior to consulting
a physician. The typical complaints will
be the symptoms previously discussed: bleeding,
protrusion, slight pain and itching or perianal
irritation. Improper bowel patterns, prior
treatment, OTC medications, constitutional
diseases such as IBS, ulcerative colitis,
Crohn's disease, and so on, should all be
excluded as possible contributors to this
condition and need to be addressed. Dietary
history, as it may be related to proper bowel
pattern, should be discussed.
Inspection: Visual inspection of
the external perianal skin is essential in
the differential diagnosis of this condition.
All types of hemorrhoids (prolapsing internal,
mixed, external and strangulated) are readily
visible and recognized by the experienced
clinician.
Anoscopy: This is the definitive
examination to determine the extent of the
hemorrhoidal condition. The use of a disposable
anoscope (Hinkel-James) is best when performing
this procedure, and at times a topical anesthetic
may be indicated to reduce discomfort. Mild
straining by the patient at times may help
assess the amount of prolapse present. Other
conditions, such as hypertrophied anal papilla,
rectal polyps, anal fissures, and so on,
also might be disclosed.
Proctosigmoidoscopy: This procedure
is used to best assess the condition of the
rectum and the lower bowel. The flexible
sigmoidoscope allows the examiner to readily
view the status of the bowel mucosa (Crohn's
disease, ulcerative colitis, IBS, etc.) and
exclude or confirm the presence of colorectal
cancer.
Treatment of Hemorrhoids
When a diagnosis of hemorrhoids is made
and the origin of the bleeding has determined
the etiology to be that of hemorrhoids, the
following treatment options may be employed.
Medical: There are lifestyle changes
that need to be made when hemorrhoids are
present. It is essential that the patient
be aware that straining during the defecatory
act be minimized, and that the act of defecation
not be prolonged. Many people make a "library
out of the bathroom," causing intense aggravation
of any anorectal disease. I recommend a hydrophilic
bulk-forming agent (psyillium based) to soften
the stool, and advise to refrain from the
use of chemical laxatives (Cascara sagrada,
Senna), as dependency may occur. Hot sitz
baths (Epsom salts), stool softeners and
anal suppositories/topical soothing agents
comprise the first line of treatment. Dietary
changes must be discussed, such as excluding
those foods that may irritate the hemorrhoidal
condition (alcohol, spicy foods, coffee,
etc.) and including those foods that may
add necessary natural bulk to promote normal
bowel activity (high fiber). Adequate fluid
intake (six to eight glasses of water daily)
is necessary to promote proper consistency
of the stool.
Rubber band ligation: This involves
the use of a device called a "Baron's ligator," whereby
a constricting rubberband is placed around
the prolapsing hemorrhoid, restricting its
blood flow and constricting the tissue until
it becomes necrotic. The "dead" hemorrhoidal
tissue sloughs and is replaced by minimal
scar tissue. This type of treatment is best
for 1st, 2nd and early 3rd degree internal
hemorrhoids. Please note that it can only
be used for lesions above the anorectal line.
The biggest unwanted side effect is pain
when the ligator mistakenly includes tissue
from the upper canal in the ligated tissue.
This eventually will cause possible ulceration,
fissure formation and intense sphincter spasms.
Another side effect is intense bleeding,
to the extent that hospitalization is required.
This occurs when the sloughing tissue exposes
its arterial supply and blood loss becomes
excessive.
Sclerotherapy: This is the injection
of 5 percent phenol in vegetable oil submucosally
above the hemorrhoid. Usually 3 to 5 cc is
placed at each hemorrhoid site. This is a
procedure that has its origin in Great Britain.
It causes fixation, retraction and partial
atrophy of the hemorrhoidal disease. It is
indicated in 1st and 2nd degree internal
hemorrhoids and is very effective. Possible
side effects are scar tissue formation and
rectal stricture, which usually occur if
there are excess amounts of the phenol and
oil solution is injected. It is contraindicated
in patients with ulcerative colitis, leukemia,
lymphoma or portal hypertension. For some
reason, this technique has lost clinical
popularity and is not readily available.
Cryotherapy: This is the destruction
of hemorrhoids by freezing with liquid nitrogen
(-180 degree Celsius). This technique had
a brief window of popularity, but is no longer
clinically popular. I had experience with
this procedure and found it not practical,
as storage of the liquid nitrogen is difficult
and instructions for its use state that one
should apply the "probe" to the tissue
until it turns white" and then remove. This
is not exact enough for the clinician and
the amount of tissue that sloughs is somewhat
unpredictable.
Infared Photocoagulation (IRPC):
This is the application of a laser-like devise
that emits infrared light that causes destruction
of the diseased tissue. It is applied in
bursts of 0.5 to 3 seconds per site and is
effective on 1st, 2nd and 3rd degree internal
hemorrhoids. Side effects are similar to
other treatments: bleeding, pain and rectal
stricture. I had extensive experience with
this procedure and the biggest problem was
equipment failure. The disposable tips were
very expensive and the power generator spent
more time at the manufacturer than in my
office.
Surgical hemorrhoidectomy: This
procedure is reserved for the most severe
cases of hemorrhoidal disease. When one has
3rd or 4th degree internal hemorrhoids and
coexistent prolapsus, closed hemorrhoidectomy
might be the only option. In my practice,
it is unusual to see a clinical situation
in which hemorrhoidectomy is necessary, but
when indicated, this may be the patient's
only viable option. The procedure is just
a matter of dissecting the diseased tissue
from the anal verge up to the anorectal ring
and then closing the wound. There usually
are three incision sites, located in the
right posterior, right anterior and left
lateral quadrants. Bleeding is controlled
by electrotherapy and running sutures. Needless
to say, this procedure is postsurgically
one of the most painful experiences an individual
will ever endure. Complications are bleeding,
intense postoperative pain and scar tissue
formation, which may lead to proctostenosis,
or a narrowing of the anorectal canal. Sometimes
the opposite occurs: Division or inadvertent
muscle/neurological damage may lead to incontinence
or wet anus syndrome. When possible, it clearly
is obvious that one should resort to all
non-surgical options prior to submitting
to surgical hemorrhoidectomy.
Negative galvanic treatment/"Keesey" treatment: This type
of non-surgical treatment involves the application of a negative
galvanic current by way of a disposable metallic electrode to the
diseased hemorrhoidal tissue. It was first discovered by W.E. Keesey,
who published an article in 1934 on its clinical application. The
negative galvanism causes NaOH (sodium hydroxide) to form at the
contact point of the negative electrode, thus causing thrombogenesis
and destruction of the hemorrhoidal vascular bed, leading to reduction
and removal of internal hemorrhoids. The amount of current usually
is somewhere between 15 to 18 Ma for approximately five to seven
minutes per treatment site. The number of treatments is determined
by the severity of the hemorrhoidal disease. Treatment may easily
be administered on consecutive days with as many as three or four
treatments in a 24-hour period. The typical case with 2nd or 3rd
degree internal hemorrhoids may require eight to 12 treatments. Side
effects include pain and bleeding, but remember that the mucosa is
void of somatic sensory enervation, allowing this treatment to be
administered with little or no discomfort. I have used a variety
of the aforementioned non-surgical treatments (ligation, IRPC etc.),
and have found that the negative galvanic (Keesey) technique is the
best tolerated, most effective and has the least likelihood of initiating
unwanted side effects (pain, bleeding, infection, etc.). In my 30
years of practice, I have administered approximately 80,000 Keesey
treatments with few complications and very good outcome. This treatment
offers the patient with a great alternative to conventional surgical
procedures and a predictable outcome that is quite satisfactory.
I hope this brief outline has enlightened the reader as to his or
her options when addressing annoying hemorrhoidal conditions. Please
be mindful that there are a myriad of diseases that occur in or around
the anorectum and colon, and proper examination is necessary to make
a positive diagnosis. The potential for symptoms to be caused by
other conditions, such as anal fissures, fistula disease, rectal
prolapse, pruritus ani (itching), perianal abscess, skin tags, venereal
disease (condyloma, herpes, gonorrhea), perianal skin cancer, and
colorectal cancer, emphasizes the importance of proper diagnosis.
About Dr. Cranford
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