Hemorrhoids

• Hemorrhoids, also called piles, are swollen, inflamed veins around the anus or lower rectum. Hemorrhoids are either inside the anus or under the skin around the anus, and often result from chronic (long term) straining to have a bowel movement. Other factors that may lead to hemorrhoids include pregnancy, aging, and chronic constipation or diarrhea.
• Hemorrhoids are very common in both men and women. The American College of Gastroenterology estimates that about half of all individuals have hemorrhoids by age 50. The most common symptom of hemorrhoids inside the anus is bright red blood covering the stool, on toilet paper or in the toilet bowl. Symptoms usually go away within a few days. Hemorrhoids can be recurrent and are more likely to occur in those having symptoms in the past.
• Hemorrhoids are also common among pregnant women. The pressure of the fetus on the abdomen, as well as hormonal changes, can cause the hemorrhoidal vessels in the anus to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem.

• Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching, also called pruritus ani, have similar symptoms and are incorrectly referred to as hemorrhoids. Anal fissures are cuts or tears occurring in the anus. An anal fistula is a small tunnel with an internal opening in the anal canal and an external opening in the skin near the anus. It forms when an anal abscess that's drained (either on its own or via surgery) does not heal completely. An anal abscess is a collection of pus in the deep tissues surrounding the anus.
• Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days.
• Hemorrhoid symptoms usually depend on the location.
• Internal hemorrhoids: Internal hemorrhoids cannot be seen or felt. Straining or irritation from passing stool can injure a hemorrhoid's delicate surface and cause it to bleed. Individuals may notice small amounts of bright red blood on toilet tissue or in the toilet bowl water. Because internal anal membranes lack pain-sensitive nerve fibers, these hemorrhoids usually do not cause discomfort. Occasionally, straining can push an internal hemorrhoid through the anal opening. If a hemorrhoid remains displaced (called prolapsed), it can cause pain and irritation. Internal hemorrhoids may not be noticed since they do not cause pain and discomfort.
• External hemorrhoids: External hemorrhoids tend to be painful. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus), causing severe pain, swelling, and inflammation. External hemorrhoids can itch or bleed when irritated.
• When internal and external hemorrhoids occur at the same time, they are referred to as mixed hemorrhoids.

• A thorough evaluation and proper diagnosis by the doctor is important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer, bleeding ulcers, inflammatory bowel diseases (such as Crohn's disease and ulcerative colitis), and anal tears.
• A doctor will examine the anus and rectum to look for swollen blood vessels that indicate hemorrhoids and will also perform a digital rectal exam with a gloved, lubricated finger to feel for abnormalities.
• Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope. An anoscope is a hollow, lighted tube useful for viewing internal hemorrhoids. A proctoscope is more useful for completely examining the entire rectum.
• To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and lower colon, or sigmoid, with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.

• Hemorrhoids can produce several uncomfortable, but non-serious problems. A blood clot in the hemorrhoid may cause severe pain and usually demands immediate medical attention. Hemorrhoids can ooze fresh red blood, whether located externally or internally. External hemorrhoids often cause dripping of blood from the anus while sitting on the toilet. The blood might also be seen as a stain on the underwear. Internal hemorrhoids that bleed may produce fresh blood in the stool. External hemorrhoids can be itchy, especially if the area is moist and irritated.
• Hemorrhoids do not develop into cancer. However, both hemorrhoids and cancer can cause rectal bleeding. In fact, many disorders can be the cause of rectal bleeding. When rectal bleeding occurs in persons over age 30, and especially in those over age 50, it should be considered a serious problem until an exact diagnosis is made.

• Medical treatment of hemorrhoids is directed initially at relieving symptoms. Measures to reduce symptoms include: soaking in a bath several times a day in plain, warm water for about 10 minutes; application of a hemorrhoidal cream or suppository, such as hydrocortisone (Anusol-HC®), to the affected area; and application of witch hazel preparations (Tucks® medicated pads). If signs and symptoms do not improve within three to five days, medical attention may be necessary.
• Preventing the recurrence of hemorrhoids will require relieving the pressure and straining of constipation. Doctors will often recommend increasing fiber and fluids in the diet. Eating the right amount of fiber and drinking six to eight glasses of water results in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding.
• Good sources of fiber are fruits, vegetables, and whole grains. In addition, doctors may suggest a bulk stool softener or a fiber supplement such as psyllium (Metamucil®) or methylcellulose (Citrucel®).
• In some cases, hemorrhoids must be treated endoscopically or surgically. These methods are used to shrink and destroy the hemorrhoidal tissue. A doctor will perform the procedure during an office or hospital visit.
• A number of methods may be used to remove or reduce the size of internal hemorrhoids. These techniques include:
• Rubber band ligation:
  During a rubber band ligation, a rubber band is placed around the base of the hemorrhoid inside the rectum. The band cuts off circulation, and the hemorrhoid withers away within a few days. Pain is likely for 24-48 hours after rubber band ligation. Individuals may be instructed to use mild pain relievers (such as acetaminophen or Tylenol®) and sit in a shallow tub of warm water (sitz bath) for 15 minutes at a time to relieve discomfort. To reduce the risk of bleeding, it is best to avoid taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin for four to five days both before and after rubber band ligation. Bleeding may occur seven to 10 days after surgery, when the hemorrhoid falls off. Bleeding is usually slight and stops by itself.
• Sclerotherapy: Sclerotherapy is a procedure used to treat blood vessels or blood vessel malformations (vascular malformations) and also those of the lymphatic system. A medicine is injected into the vessels, which makes them shrink. It is used for children and young adults with vascular or lymphatic malformations. In adults, sclerotherapy is often used to treat varicose veins and hemorrhoids. During sclerotherapy, a chemical solution is injected around the blood vessel to shrink the hemorrhoid. Although rare, complications may include venous thromboembolism (formation of a blood clot in a blood vessel that breaks loose and is carried by the blood stream to plug another vessel), visual disturbances, allergic reaction, thrombophlebitis (swelling of a vein caused by a blood clot), skin necrosis (skin death), and hyperpigmentation.
• Infrared coagulation: During infrared coagulation, a special device using an infrared beam of light is used to burn hemorrhoidal tissue. Mild discomfort and pain may occur. This procedure is usually done on an out-patient basis with no hospital stay required.
• Hemorrhoidectomy: A hemorrhoidectomy is surgery to remove hemorrhoids. Hemorrhoidectomy is often used when other procedures have not been successful or if the hemorrhoids are large. The surgery is done with either a local anesthetic combined with sedation, a spinal anesthetic, or a general anesthetic. Surgery can be performed on an outpatient basis or may require an overnight hospital stay. While the individual may experience discomfort after the procedure, medications can be used to relieve the pain. Soaking in a warm bath also can ease discomfort.

C

Unclear or conflicting scientific evidence

• Chamomile
  : Chamomile (Matricaria recutita or Chamaemelum nobile) has been used medicinally for thousands of years, and is widely used in Europe. Preliminary study reports that chamomile ointment may improve hemorrhoids. Better evidence is needed before a recommendation can be made.
• Avoid if allergic to chamomile. Anaphylaxis, throat swelling, skin allergic reactions and shortness of breath have been reported. Chamomile eyewash can cause allergic conjunctivitis (pinkeye). Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.
• Ginkgo
  : Ginkgo biloba has been used medicinally for thousands of years. Today, it is one of the top selling herbs in the United States. In early study, ginkgo was shown to be effective in the treatment of patients with acute hemorrhoidal attacks. Further research is needed to confirm these results.
• Avoid if allergic or hypersensitive to members of the Ginkgoaceae
  family.
  If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin®)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Ginkgo should not be used in supplemental doses if pregnant or breastfeeding.
• Hydrotherapy
  : Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. There is preliminary evidence supporting the use of sitz baths for people with anorectal lesions such as hemorrhoids and anal fissures, particularly for symptom relief. Sitz baths are offered to patients in many hospitals. However, controlled studies are needed to determine the effectiveness and optimal use of sitz baths. A sitz bath can refer to a bath where the pelvic region is immersed in warm water, or to a type of tub, which makes taking the sitz bath easier.
• Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices like pacemakers, defibrillators, or hepatic (liver) infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, and impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physician(s) before starting hydrotherapy.
• Psyllium
  : Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of Plantago ovata. Psyllium contains a high level of soluble dietary fiber, and is the chief ingredient in many commonly used bulk laxatives, including products such as Metamucil®. Human studies report that psyllium containing products reduced symptoms of hemorrhoids. Further evidence is needed to confirm these results.
• Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantain (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Avoid ingestion of psyllium-containing products in individuals with repeated or prolonged psyllium exposure who have not manifested allergic or hypersensitive symptoms. Psyllium may decrease the amount of medications (both prescription and OTC) available to the body. If using psyllium products, take medications at least one hour before or two hours after psyllium. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.
• Rutin
  : Rutin is an antioxidant found mainly in citrus fruits. Preliminary evidence suggests that rutin may be a safe and effective treatment for hemorrhoids. Studies investigating the effect of rutin in different populations, as well as efficacy on third or fourth degree hemorrhoids, are warranted in future studies.
• Avoid if allergic/hypersensitive to O-(beta-hydroxyethyl)-rutosides or plants that rutin is commonly found in, such as rue, tobacco or buckwheat. Use cautiously in elderly patients. Use cautiously with skin conditions. Use cautiously if taking medications for edema, diuretics, or anti-coagulation medications. Use cautiously if pregnant or breastfeeding.
• Witch hazel
  : Witch hazel is a common ingredient in over-the-counter skin preparations for hemorrhoids; however, human study evaluating the effectiveness for this indication is currently lacking.
• Avoid if allergic or sensitive to witch hazel. Avoid if pregnant or breastfeeding. Use cautiously in people with liver or kidney disorders, diabetes, and in children.

• Healthcare professionals recommend the following for prevention of hemorrhoids:
• High-fiber foods:
  Eat more fruits, vegetables, and grains. Doing so softens the stool and increases its bulk, which will help lessen the straining that can cause hemorrhoids or worsen symptoms from existing hemorrhoids.
• Plenty of liquids: Plenty of fluids (non-sweetened drinks and water) should be consumed. The amount of daily fluid requirements depends on age, sex, health, activity level, and other factors. In general, six to eight, 8 ounce glasses of water is sufficient.
• Fiber supplements: Over-the-counter (OTC) products such as psyllium (Metamucil®) and methylcellulose (Citrucel®) can help keep stools soft and regular. Check with a doctor about using stool softeners. If fiber supplements are used, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, fiber supplements can cause constipation or make constipation worse. Add fiber to the diet slowly to avoid gas.
• Exercise:
  Staying active helps to reduce pressure on veins, which can occur with long periods of standing or sitting, and to help prevent constipation. Exercise can also help the individual lose excess weight that may be contributing to hemorrhoids. In general, exercising at least 30 minutes daily, five days a week is recommended by healthcare professionals.
• Avoid long periods of standing or sitting:
  Sitting too long, particularly sitting on the toilet for long periods, can increase the pressure on the veins in the anus. Taking periodic breaks from sitting is recommended by healthcare professionals.
• Eliminating straining:
  Straining and holding the breath when trying to pass a stool creates greater pressure in the veins in the lower rectum and may lead to hemorrhoids.