Haemorrhoids

Haemorrhoids (Greek: haima blood, rhoos = flowing) syn. piles1 (Latin: pila = a ball) are dilated veins occurring in relation to the anus. Such haemorrhoids may be external or internal, i.e. external or internal to the anal orifice. The external variety is covered by skin, while the internal variety lies beneath the anal mucous membrane. When the two varieties are associated, they are known as interoexternal haemorrhoids.

The veins which form internal haemorrhoids become engorged as the anal lining descends and is gripped by the anal sphincters. The mucosal lining is gathered prominently in three places (the ‘anal cushions’), which can be in the areas of the three terminal branches of the superior haemorrhoidal artery, but this is exceptional (Thomson). The anal cushions are present in embryonic life and are necessary for full continence. Straining causes these cushions to slide downwards and internal haemorrhoids develop in the prolapsing tissues.

Haemorrhoids may be symptomatic of some other condition, and this important fact must be remembered. Symptomatic haemorrhoids may appear:

in carcinoma of rectum. This, by compressing or causing thrombosis of the superior rectal vein, gives rise to haemorrhoids (Fig. 61.24) sufficiently often to warrant examination of the rectum and the rectosigmoid junction for a neoplasm in every case of haemorrhoids;

during pregnancy. Pregnancy piles are due to compression of the supe­rior rectal veins by the pregnant uterus and the relaxing effect of progesterone on the smooth muscle in the walls of the veins, plus an increased pelvic circulating volume;

from at raining at micturition consequent upon a stricture of the ure­thra — or an enlarged prostate;

from chronic constipation.

NB. Contrary to the usual belief, in 128 consecutive cases of portal hypertension, Macpherson did not encounter a single example of haemorrhoids that could be attributed to portal cirrhosis, although bleeding oesophageal varices often complicate portal hypertension.

The great majority of haemorrhoids is not symptomatic. The description that follows concerns symptomatic haemorrhoids that are not secondary to an underlying cause.

Internal haemorrhoids

Internal haemorrhoids, which include intero-external haemorrhoids, are exceedingly common. Essentially, the condition is a dilatation of the internal venous plexus with an enlarged displaced anal cushion. Because of the communication between the internal and external plexuses, if the former becomes engorged, the latter is liable to become involved also.

Aetiology

Hereditary. The condition is so frequently seen in members of the same family that there must be a predisposing factor, such as a congenital weakness of the vein walls or an abnormally large arterial supply to the rectal plexus.

Varicose veins of the legs and haemorrhoids often occur concurrently. Morphological. In quadrupeds, gravity aids, or at any rate does not retard, return of venous blood from the rectum. Consequently venous valves are not required. In humans, the weight of the column of blood unassisted by valves produces a high venous pressure in the lower rectum, unparalleled in the body. Except in a few fat old dogs, haemorrhoids are exceedingly rare in animals.

Anatomical. The collecting radicles of the superior haemorrhoidal vein lie unsupported in the very loose submucous connective tissue of the anorectum. These veins pass through muscular tissue and are liable to be constricted by its contraction during defecation. The superior rectal veins, being tributaries of the portal vein, have no valves.

Exacerbating factors. Straining accompanying constipation or that induced by over purgation is considered to be a potent cause of haemorrhoids. Less often, the diarrhoea of enteritis, colitis or the dysenteries aggravates latent haemorrhoids. In both instances, descent and swelling of the anal cushions are prominent features.

Pathology

Internal haemorrhoids are frequently arranged in three groups at 3, 7, and 11 o’clock with the patient in the litho­tomy position [in which patients used to be put for the classical operation of ‘cutting’ for bladder stone via the urethral or the perineal route (Chapter 62)]. This distribution has been ascribed to the arterial supply of the anus whereby there are two subdivisions of the right branch of the superior rectal artery, but the left branch remains single (Fig. 61.25), but this is now known to be atypical. In between these three primary haemorrhoids there may be smaller secondary haemorrhoids. Each principal haemorrhoid can be divided into three parts.

The pedicle is situated at the anorectal ring. As seen through a proctoscope, it is covered with pale pink mucosa. Occasionally, a pulsating artery can be felt in this situation.

  The internal haemorrhoid, which commences just below the anorectal ring. It is bright red or purple, and covered by mucous membrane. It is of variable size.

An external associated haemorrhoid lies between the den­tate line and the anal margin. It is covered by skin, through which blue veins can be seen, unless fibrosis has occurred.

  This associated haemorrhoid is present only in well-established cases.

Entering the pedicle of an internal haemorrhoid may be a branch of the superior rectal artery. Very occasionally there is a haemangiomatous condition of this artery — an ‘arterial pile’—which leads to ferocious bleeding at operation.

 

Clinical features

 

Symptoms of haemorrhoids

 

  Bright red painless bleeding

  Mucus discharge

Prolapse

Pain only on prolapse

Bleeding, as the name haemorrhoid implies, is the principal and earliest symptom. At first the bleeding is slight; it is bright red and occurs during defecation (a ‘splash in the pan’), and it may continue intermittently thus for months or years. Haemorrhoids that bleed but do not prolapse outside the anal canal are called first-degree haemorrhoids.

Prolapse is a much later symptom. In the beginning the protrusion is slight and occurs only at stool, and reduction is spontaneous. As time goes on the haemorrhoids do not reduce themselves, but have to be replaced digitally by the patient. Haemorrhoids that prolapse on defecation but return or need to be replaced manually and then stay reduced are called second-degree haemorrhoids. Still later, prolapse occurs during the day, apart from defecation, often when patients are tired or exert themselves. Haemorrhoids that are permanently prolapsed are called third-degree haemorrhoids (Fig. 61.26). By now, the haemorrhoids have become a source of great discomfort and cause a feeling of heaviness in the rectum but are not usually acutely painful.

Discharge. A mucoid discharge is a frequent accompani­ment of prolapsed haemorrhoids. It is composed of mucus from the engorged mucous membrane, sometimes augmented by leakage of ingested liquid paraffin. Pruritus will almost certainly follow this discharge.

Pain is absent unless complications supervene. For this reason, any patient complaining of ‘painful piles’ must be suspected of having another condition (possibly serious) and examined accordingly.

Anaemia can be caused very rarely by persistent profuse bleeding from haemorrhoids.

Investigation

On inspection there may be no evidence of internal haemorrhoids. In more advanced cases, redundant folds or tags of skin can be seen in the position of one or more of the three primary haemorrhoids. When the patient strains, internal haemorrhoids may come into view transiently or, if they are of the third degree, they are, and remain, prolapsed.

Digital examination. Internal haemorrhoids cannot be felt unless they are thrombosed.

Proctoscopy. A proctoscope is passed to its fullest extent and the obturator is removed. The instrument is then slowly with­drawn. Just below the anorectal ring internal haemorrhoids, if present, will bulge into the lumen of the proctoscope.

Sigmoidoscopy should be done as a precaution in every

case (Chapter 60 and Fig. 60.5).

Complications

Profuse haemorrhage is not rare. Most often it occurs in the early stages of the second degree. The bleeding occurs mainly externally, but it may continue internally after the bleeding haemorrhoid has retracted or has been returned. In these circumstances, the rectum is found to contain blood.

Strangulation. One or more of the internal haemorrhoids prolapse and become gripped by the external sphincter. Further congestion follows because the venous return is impeded. Second-degree haemorrhoids are most often complicated in this way. Strangulation is accompanied by considerable pain, and is often spoken of by the patient as an ‘acute attack of piles’ [a phrase that also embraces a thromhotic pile (see below) or an inflamed anal skin iag]. Unless the internal haemorrhoids can be reduced within an hour or two, strangulation is followed by thrombosis.

Thrombosis. The affected haemorrhoid or haemorrhoids become dark purple or black (Fig. 61.27) and feel solid. Considerable oedema of the anal margin accompanies thrombosis. Once the thrombosis has occurred, the pain of strangulation largely passes off, hut tenderness persists.

Ulceration. Superficial ulceration of the exposed mucous membrane often accompanies strangulation with thrombosis.

Gangrene occurs when strangulation is sufficiently tight to constrict the arterial supply of the haemorrhoid. The resulting sloughing is usually superficial and localised. Occasionally, a whole haemorrhoid sloughs off, leaving an ulcer which heals gradually. Very occasionally, massive gangrene extends to the mucous membrane within the anal canal and rectum, and can be the cause of spreading anaerobic infection and portal pyaemia.

Fibrosis. After thrombosis, internal haemorrhoids sometimes become converted into fibrous tissue. The fibrosed haemorrhoid is at first sessile, but by repeated traction during prolapse at defecation, it becomes pedunculated and constitutes a fibrous polyp that is readily distinguished by its white colour from an adenoma, which is bright red. Fibrosis following transient strangulation commonly occurs in the subcutaneous part of a primary haemorrhoid. Fibrosis in an external haemorrhoid favours prolapse of an associated internal haemorrhoid.

Suppuration is uncommon. It occurs as a result of infection of a thrombosed haemorrhoid. Throbbing pain is followed by perianal swelling, and a perianal or submucous abscess results.

Pylephlebitis (syn. portal pyaemia). Theoretically, infected haemorrhoids should be a potent cause of portal pyaemia and liver abscesses (Chapter 52). Although cases do occur from time to time, this complication is surprisingly infrequent. It can occur when patients with strangulated haemorrhoids are subjected to ill advised surgery and has even been reported to follow banding (see below).

 

Treatment

 

Treatment of haemorrhoids

 

Symptomatic

Injection of sclerosant

Banding

Photocoagulation

Haemorrhoidectomy

Nonoperative treatment is recommended when the haemorrhoids are a symptom of some other condition or disease except, of course, when a carcinoma is present. The bowels are regulated by hydrophyllic colloids (Isogel, etc.) and if necessary a small dose of Senokot at night. Various proprietary creams can be inserted into the rectum from a collapsible tube fitted with a nozzle, at night and before defecation. Suppositories are also useful.

Active treatment. This consists of injection or treatment by elastic band applications to the base of each haemorrhoid or formal operation, each with specific indications. Treatment should not be withheld because the patient is elderly or infirm.

Injection treatment (Mitchell). Indications. This is ideal for first-degree internal haemorrhoids which bleed. Early second-degree haemorrhoids are often cured by this method but a proportion relapses.

Technique. The patient should have an empty rectum, but no special preparation is necessary. A proctoscope is introduced and the haemorrhoids are displayed. The proctoscope is introduced further in until the haemorrhoid has almost disappeared from the lumen and only its upper end is visible. The injection is made at this point above the main mass of each haemorrhoid (Fig. 61.28) into the submucosa at, or just above, the anorectal ring. Using Gabriel’s syringe or more commonly a disposable instrument (Fig. 61.29) with the bevel of the needle directed towards the rectal wall, from 3 to 5 ml of 5 per cent phenol in almond oil is injected. The injection should produce elevation and pallor of the mucosa. The solution spreads in the submucosa upwards to the pedicle, and downwards to the internal haemorrhoid and to secondary haemorrhoids if present, but it is prevented by the intermuscular septum from reaching the external haemorrhoid. There is slight, transient bleeding from the point of puncture. The injection is painless, but a dull ache is common for a few hours. There is no special after-treatment. If there is only one haemorrhoid present, it may be cured by one injection; if all three haemorrhoids are equally enlarged, each is injected at the same session. Often three sessions at 6-weekly intervals are required. Care should be taken not to inject into the prostate anteriorly, for the resulting prostatitis can be crippling.

Banding treatment (Barron)

For second-degree haemorrhoids which are too large for successful handling by injections, treatment is available by slipping tight elastic hands on to the base of the pedicle of each haemorrhoid with a special instrument (Fig. 61.30). The bands cause ischaemic necrosis of the piles, which slough off within a few days. The procedure should be painless if done properly, and can be performed in the out-patient department. Not more than two haemorrhoids should be banded at each session and 3 weeks at least should elapse between each treatment.

Cryosurgery

The application of liquid nitrogen has been evaluated in some centres. The extreme cold (-196’C) of the application causes coagulation necrosis of the piles, which subsequently separate and drop off. Although some encouraging early results were reported (Lloyd-Williams), the technique often caused troublesome mucus discharge and pain, and has now been abandoned.

Photocoagulation

 

The application of infrared coagulation by a specially designed instrument has recently been advocated for the treatment of haemorrhoids that do not prolapse (Leicester). This is said to be an effective and painless method of treatment.

 

Operation. Indications. Cases unsuitable for injection or banding treatment are:

 

  third-degree haemorrhoids;

failure of nonoperative treatments of second-degree haem­orrhoids;

  fibrosed haemorrhoids;

      intero-external haemorrhoids when the external haemorrhoid is well defined.

These are indications for haemorrhoidectomy.

Haemorrhoidectomy

Some preoperative treatment is necessary. An aperient is given on the evening before the operation and an enema is administered. The anal region is shaved. On the morning of the operation the rectum is evac­uated with the aid of a disposable enema.

Haemorrhoidectomy can be performed using an open or a closed technique. The open technique is most commonly used in the UK, and is known as the Milligan-.Morgan operation — named after the surgeons who described it. The closed technique is the popular technique in the USA. Both involve ligation and excision of the haemorrhoid, but in the open technique the anal mucosa and skin are left open to heal by secondary intention, and in the closed technique, the wound is sutured.

Open technique. With the patient in the lithotomy position, the sphincter is gently stretched, and the internal haemorrhoids are then prolapsed by traction on the skin tags, or on the skin of the anal margin. Each haemorrhoid is dealt with as follows: it is picked up with dissecting forceps and traction is exerted. Traction displays a longitudinal fold (the pedicle) above the haemorrhoid. Each pedicle is grasped in a fine-pointed haemostat, as also is each external haemorrhoid or skin tag connected with each internal haemorrhoid. These pairs- of haemostats, when held out by the assistants, form a triangle. The operator takes the left lateral pair of haemostats in the palm of his hand and places the extended forefinger in the anal canal to support the internal haemorrhoid. In this way traction is applied to the skin of the anal margin. With scissors, a shaped cut is made (Fig. 61.31a), each limb of which is placed on either side of the skin holding haemostat. This cut transverses the skin and the corrugator cons ani. Exerting further traction a little blunt dissection exposes the lower border of the internal sphincter. A transfixion ligature of no. 3 chromic catgut is applied to the pedicle at this level (Fig. 61.31b). Each haemorrhoid, having been dealt with in this manner (Fig.61.31c), is excised 1.25 cm distal to the ligature, the ends of which are cut about 1 cm from the knot. The stumps of the ligated haemorrhoids ate returned to the rectum by tucking a piece of gauze into the anal canal.

The margins of the skin wounds are trimmed so as not to leave overhanging edges (Fig. 61.32). Bleeding subcutaneous arteries having been secured, the corners of three pieces of petroleum-jelly gauze are tucked into the anus so as to cover the areas denuded of skin. A pad of gauze and wool and a firmly applied T-bandage complete the operation.

Closed technique (Fig. 61.33). The patient is placed in the prone jack­knife position with the buttocks strapped apart. A suitable retractor, such as the Hill—Ferguson type, is placed within the anal canal, and the anus is infiltrated with 20 ml of a 1 in 300 000 adrenaline—saline solution. The haemorrhoid is excised, together with the overlying mucous, as illustrated in Fig. 61.33a. The haemorrhoid is dissected carefully from the underlying sphincter and haemostasis is achieved. The pedicle is transfixed and ligated with 3.0 chromic catgut or Dexon. Any residual small haemorrhoids should be removed by filleting them out after undermining the edges of the cut mucosa. The mucous1 defect is then closed completely with a continuous suture using the same stitch that was employed to ligate the haemorrhoid pedicle. The remaining haemorrhoids are excised and ligated in similar fashion, ensuring there are adequate mucosal and skin bridges between each area of excision, so as to avoid a subsequent stenosis.

Postoperative care. In these days of economic stringencies, the patient is discharged from hospital within a day or two of the operation. In the USA, the procedure is often performed on a day-care basis. The patient is instructed to take two warm baths a day, and is given a bulk laxative to take twice daily, together with appropriate analgesia. Dry dressings are applied as necessary, a sterile sanitary towel usually being ideal. The patient is seen again 3—4 weeks after discharge and a rectal examination is performed. If there is evidence of stenosis, the patient is encouraged to use a dilator.

Postoperative complications may be early or late.

Complications of haemorrhoidectomy

Early Late
Pain Secondary haemorrhage
Acute retention of urine Anal stricture
Reactionary haemorrhage Anal fissure

Early. Pain may demand repeated pethidine. Xylocaine jelly introduc­ed through a fine nozzle into the rectum, as necessary, is of considerable value.

Retention of urine is not unusual after haemorrhoidectomy in male patients, and frequently it is precipitated by the presence of a rectal tube or pack, or both. Before resorting to catheterisation, the patient should be reassured, given an analgesic, allowed to stand at the side of the bed in privacy or be assisted to a hot bath into which he may be able to void urine.

Reactionary haemorrhage is much more common than secondary haemorrhage. The haemorrhage may be mainly or entirely concealed, but will become evident on examining the rectum.

Treatment. A suitable dose of morphine is given intravenously. If the bleeding persists, the patient must be taken to the operating theatre and the bleeding point secured by diathermy or under-running with a ligature on a needle. Should a definite bleeding point not be found, suspected areas are under-run in this way and the anal canal and rectum are packed.

Late. Secondary haemorrhage is uncommon; when it occurs, it does so about the 7th or 8th day after operation. It is usually controlled by morphia but, if the haemorrhage is severe, an anaesthetic should be given and a catgut stitch inserted to occlude the bleeding vessel.

Anal stricture. This must be prevented at all costs (Fig. 61.32 and legend). A rectal examination at the 10th day will indicate whether stricturing is to be expected. It may then be necessary to give a general anaesthetic and dilate the anus. After that, daily use of the dilator should give a satisfactory result.

Anal fissure and submucous abscesses may also occur.

Treatment of complications

Strangulation, thrombosis and gangrene. In these cases, it was formerly believed that surgery would promote pylephlebitis. If adequate antibiotic cover is given from the start, this is not found to be so and immediate surgery can be justified in many patients. Besides adequate pain relief, bed rest with frequent, hot sitz baths and warm saline compresses with firm pressure usually cause the pile mass to shrink considerably in 3—4 days when standard ligation and excision of the piles can be carried out. Some surgeons consider that the operation at this stage increases the risk of postoperative stenosis and delay surgery for a month or so. They then review the situation and only carry out haemorrhoidectomy if necessary. In spite of the low risk of pylephlebitis, caution should dictate a ‘noninterventionist’ policy whenever this is practical. An anal dilation technique has in the past been used as an alternative treatment to surgery for painful ‘strangulated’ haemorrhoids. However, the stretching should be far more circumspect than that recommended by Lord in his original description and the patient must be warned about other risks of incontinence. Once again an anal stretch must be avoided in patients with a weak or potentially weak anal sphincter. Many colorectal surgeons have abandoned the use of anal stretch in any circumstances.

Severe haemorrhage. The cause usually lies in a bleeding diathesis or the use of anticoagulants. If such are excluded, a local compress containing adrenaline solution, with an injection of morphine and blood transfusion if necessary, will usually control the haemorrhage. After blood replacement is adequate, ligation and excision of the piles may be required.

External haemorrhoids

Unlike internal haemorrhoids, external haemorrhoids con­sists of a conglomerate group of distinct clinical entities.

A thrombosed external haemorrhoid is commonly termed a perianal haematoma. It is a small clot occurring in the pen-anal subcutaneous connective tissue, usually superficial to the corrugator cutis ani muscle. The condition is due to back pressure on an anal venule consequent upon straining at stool, coughing or lifting a heavy weight.

The condition appears suddenly and is very painful, and on examination a tense, tender swelling which resembles a semi ripe blackcurrant is seen. The haematoma is usually situated in a lateral region of the anal margin. Untreated it may resolve, suppurate, fibrosed and give rise to a cutaneous tag, or burst and extrude the clot, or continue bleeding.

In the majority of cases resolution or fibrosis occurs. Indeed, this condition has been called ‘a 5-day, painful, self-curing lesion’ (Milligan).

Provided it is seen within 36 hours of the onset, a perianal haematoma is best treated as an emergency. Under local anaesthesia the haemorrhoid is bisected and the two halves are excised together with 1.25 cm of adjacent skin. This leaves a pear-shaped wound which is allowed to granulate. The relief of pain is immediate and a permanent cure is cer­tain. On the rare occasions in which a perianal haematoma is situated anteriorly or posteriorly, it should be treated con­servatively because of the liability of a skin wound in these regions to become an anal fissure.

Associated with internal haemorrhoids = intero-external haemorrhoids. These have been discussed.

Dilatation of the veins of the anal verge becomes evident only if the patient strains, when a bluish, cushion-like ring appears. This variety of external haemorrhoid is almost a perquisite of those who lead a sedentary life. The only treat­ment required is an adjustment in habits of the patient.

A ‘sentinel’ pile is associated with an anal fissure (see above).

Genital warts — see Chapter 67.