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
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
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
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.