December 2009 | Vol 6 | Issue12

December 2009 | Volume 6 | Issue 12



Article
 
Haemorrhoids… a Clinical study
 

 



Dr.Vaibhav J.Nilajkar, BHMS
No.6633,Plot.No:1815, Sect.No-10,
Anjanaya Nagar, Belgaum,
Karnataka , Pin : 590016
Mob : 09481348013

    Introduction:

       Haemorrhoids are itching, painful or bleeding mass of swollen tissues and varicose veins located in the anus and rectum. Haemorrhoid is a varicose dilation of the veins of internal or external rectal venous plexus.Haemorrhoid is a greek word derived from haima=blood and rhoas=flowing. Piles are a latin word from pila=a ball.

    Etiology
    Sitting for long periods of time can start the haemorrhoidic process
    Increased straining during bowel movements caused by constipation or diarrhoea may lead to haemorrhoids
    Hypertension, particularly portal hypertension
    Obesity
    Haemorrhoids are often associated with pregnancy
    Insufficient liquid can cause a hard stool, or even chronic constipation, which can lead to hemorrhoidal radiation
    Vitamin E deficiency is also a common cause
    Eating spicy food does not cause haemorrhoids, though spicy foods may aggravate the condition

    Clinical presentation
    There are two types of presentation as external and internal haemorrhoids.

    External Haemorrhoids
    External haemorrhoids are visible-occurring outside the analverge. They are also known as false piles. They are basically skin-covered veins that have ballooned and appear blue. Usually they appear without any symptoms. When inflamed, they become red and tender.
    1) Bleeding per rectum which is bright red, painless and occurs along with defaecation
    2) In proplased haemorrrhoids, the mucous discharge softens and excoriates the skin at the anus
    3) Anaemia may be seen in long standing cases of haemorrhoids due to persistent and profuse bleeding
    4) A mucoid discharge is a frequent accompaniment of prolapsed haemorrhoids. It is composed of mucous from the engorged mucous membrane. Pruritus will almost certainly present.

    Internal Haemorrhoids
    Internal haemorrhoids occur inside the rectum. These are varicosities of veins draining the territory of branches of superior rectal arteries. Bleeding is the most common symptom of internal haemorrhoids, and often only in mild cases. There are two varieties of
    Internal Haemorrhoids depending upon the causative factors

    1) Primary piles
    These are the piles where no cause can be found and they form 90% of internal haemorrhoids.

    2) Secondary piles
    These are the piles where there is a definite cause and they form 10% of the internal haemorrhoids. Haemorrhoids may be ‘symptomatic’ of some other condition and this important fact must be remembered when they are found. The cause is usually due to carcinoma of rectum, chronic constipation, portal hypertension, during pregnancy, straining for urination in prostatic enlargement or stricture of urethra.

    Pathology
    Internal haemorrhoids in associated with the terminal divisions of the superior rectal tral artery are arranged in three groups at 3, 7 and 11 o’clock position with the patient in the lithotomy position. This distribution is due to the arterial supply of the anus where by there are 2 subdivisions of the right branch of the superior rectal artery, but the left branch remains single. In between these three primary haemorrhoids there may be smaller secondary haemorrhoids. Each principle haemorrhoids can be divided into three parts.
    1) Pedicle, it is situated in the rectum just above ano-rectal ring. It is usually covered with pale pink mucosa through which large tributaries of the superior rectal vein can be seen, occasionally a pulsating artery can be felt.
    2) The internal haemorrhoids, which commences at the ano-rectal ring and ends at the dentate line .It is bright or purple covered by mucous membrane.
    3) An external associated haemorrhoids, lies between the dentate line and the anal margin. It is covered with skin, through which blue veins can be seen unless fibrosis has occurances.This is present only in well established cases.


    Sites of piles

    Diagram showing the anal opening in lithotomy position
    Primary sites are 3,7 and 11 o’clock position.
    Secondary sites are all around the dial of clock especially at the side of primary sites.

    Grade or degrees of piles
    1st Degree
    They are non-prolapsing variety ,which do not prolapse below the Helton’s Line even on straining for stools.They are seen only on Proctoscopic examination.

    2nd Degree
    Here prolapse occurs only on straining for stools and then they go back to their normal place.

    3rd Degree
    Here prolapse occurs on straining for stools but they need manual reduction to go back to their normal position.

    4th Degree
    Here the piles remain proplased all the time with or without straining.

    Diagnosis
    A thorough evaluation and proper diagnosis by the doctor is important any time when bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer. It is highly essential to examine the anus and rectum to look for swollen blood vessels that indicate haemorrhoids with a gloved lubricated finger. Closer evaluation of the rectum for haemorrhoids requires an exam with a proctoscope and sigmoidoscopy will be useful for more complete examination of the entire rectum.