HAEMORRHOIDS

Haemorrhoids are a common reason for patients seeking attention of a colorectal surgeon. Symptoms from haemorrhoids are common, with over 5% of all people having problematic haemorrhoids at some stage.

What is not well understood about haemorrhoids is that they are in fact a normal part of our anatomy, and even have a function in contributing to anal continence. Haemorrhoids are small swellings made up of tiny blood vessels just inside the anus. After passing a bowel motion, our haemorrhoids fill with a small amount of blood and meet in the middle, helping to close our anus and prevent leakage. It is thought that they contribute to about 20% of our resting anal continence.

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Appearance of normal haemorrhoids at “proctoscopy” (a small telescope within the anal canal).

With straining over many years or constipation, haemorrhoids can swell as the tissue inside them is elastic. This can lead to enlargement of the haemorrhoids and sometimes they can even stretch and “prolapse” outside the anus. One of the most common symptoms of haemorrhoids is bleeding. This is typically fresh red blood and often comes and goes. It typically is found only on the toilet paper, or may drip into the toilet bowl as well. This type of bleeding, however, is not diagnostic of haemorrhoids and a proper evaluation by a colorectal surgeon is required to ensure there is no other cause.

Some people develop haemorrhoids that enlarge and prolapse outside after every bowel motion. This can cause discomfort or be annoying and people often describe having to use their finger to push the haemorrhoid back inside. Occasionally haemorrhoids can enlarge to the point that they become stuck outside, leading to “thrombosis” or clotting of the blood in them and this results in severe pain and will often lead to a presentation to the emergency department. These “haemorrhoidal crises” can take 2-3 weeks for the pain to settle down.

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An “acutely incarcerated” haemorrhoid. This would be a painful problem.

Other symptoms that haemorrhoids can cause include itch around the anus, mucus leakage or concern about the appearance of the anus. Itch is generally a result of mucus trapping around skin tags or external haemorrhoids and can lead to excessive wiping. Mucus leakage is a result of haemorrhoids prolapsing and can also lead to itch or the sensation of moisture around the anus. Some patients are concerned about the appearance of their anus – in particular those with large skin tags and sometimes this can be improved with a surgical excision.

There are many other symptoms from the anus and rectum which people often attribute to haemorrhoids – such as difficulty going to the toilet, feeling blocked or feeling a pressure or bulge around the anus. These are not typical symptoms of haemorrhoids and a formal assessment by one of our surgeons may uncover another problem involving the bowel itself, or the structure or function of the pelvic floor.

Generally our approach at Brisbane Colorectal to people with haemorrhoids is holistic and symptom-based. We will take a history and perform an examination to assess the problem. A proctoscopy or rigid sigmoidoscopy is a fairly quick and simple test we can do in the rooms to visualise the anal canal using a light and assess the extent of someone’s haemorrhoids.

Haemorrhoids themselves are not life-threatening and the treatment we offer you will depend on what your concerns are. Some patient simply want an assessment and reassurance there is no more sinister cause of their symptoms. Other patients may be very bothered by their haemorrhoids and for these people there are many options.

We will discuss with you your dietary intake, in particular with reference to fibre intake. Bleeding from haemorrhoids responds very well to fibre supplements and we may recommend one for you. We have a dietician in our rooms who is available for a formal consultation to help people reach their dietary targets with fibre intake and healthy eating. Having a soft regular stool is equally important, and we may prescribe a stool softener for you as well.

Sometimes we may find people could benefit from an improvement in their defecatory technique. Defecation is a complex, dynamic manoeuvre and some people develop poor habits or muscle incoordination problems; there are tests that can suggest these problems and we tend to involve a pelvic floor physiotherapist in our treatment of this subgroup of patients.

A minority of patients with haemorrhoids can require surgery for relief of their symptoms, and this is dependent on how bad the symptoms are and the size and extent of the haemorrhoids. A common intervention for bleeding or prolapsing haemorrhoids is rubber band ligation. This is a minor procedure but we will generally encourage you to have this done in the endoscopy unit, where we can provide a light anaesthetic and can perform the procedure safely.

Patients with larger haemorrhoids, particularly when the anal skin is involved, may require an excisional haemorrhoidectomy. This is a surgical procedure involving removal of the haemorrhoids themselves. It has been shown, when compared to all other haemorrhoid operations, to be the most effective strategy for improvement in haemorrhoids and has the lowest “recurrence” rate of all haemorrhoid treatments. It is explained below.

Other operations involve surgical excision of “redundant” or floppy mucosa (the internal lining of the bowel) and there are a number of operations which can achieve this, including stapled haemorrhoidectomy and HAL-RAR (haemorrhoidal artery ligation and recto-anal repair).

Given the number of treatment options available, it is best to have your surgeon assess you and guide you as to the best course of treatment for your problem. Colorectal surgeons are specifically trained in the treatment of anorectal disorders and as such you are most likely to have a satisfactory outcome when treated by a colorectal surgeon.

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Large prolapsing haemorrhoids. The image on the left demonstrates haemorrhoids with a larger skin component and some ulceration. The image on the right shows very large internal haemorrhoids – these would not normally be visible to this degree in the awake patient.

RUBBER BAND LIGATION:

This is a minor procedure involving tiny rubber bands being placed internally in the rectum, usually at the origin of the haemorrhoid. It is usually performed in the endoscopy suite at Mater Private Hospital, where an anaesthetist will provide sedation for you so that you are asleep when the procedure is being done. We often perform this at the same time as an endoscopic assessment of the colon so that we can ensure that there is no other polyp or lesion in your bowel causing your symptoms. This can be a complete colonoscopy, or a flexible sigmoidoscopy which is an assessment of the lower half of the colon.

The procedure is generally painless and is a day procedure. A percentage of patients develop a dull ache after the procedure but this generally lasts a few hours then resolves. Paracetamol can be effective in alleviating this pain. More severe pain is very uncommon and usually related to the rubber bands being placed too low. Delayed bleeding is also a small risk, occurring with a frequency of about 1 in 200 procedures.

You would normally need to be in the endoscopy unit for about 3 hours from the time you arrive to when you can leave. It is important to have someone available to take you home and to be with you if you have had any anaesthetic. We cannot discharge you from hospital without someone else being available to look after you.

Rubber band ligation works by pulling the haemorrhoids back inside the anus, thereby improving symptoms of prolapse or mucus leakage. The rubber band constricts the lining of the rectum where the haemorrhoid starts, leading to scarring and this stops the haemorrhoid from stretching any more. The rubber bands fall off within a few days and are passed in the faeces, you will not notice this.

The success rate of rubber band ligation is about 50-90% and this effect usually lasts years, however it is only effective for smaller haemorrhoids with less “external component”.

EXCISIONAL HAEMORRHOIDECTOMY:

An excisional haemorrhoidectomy involves surgical excision of prolapsing haemorrhoidal tissue from the inside of the rectum, extending to the skin just on the outside of the anus. It is generally reserved for larger haemorrhoids where there is involvement or extension into the perianal skin, or significant ulceration or bleeding. Patients may have suffered from “haemorrhoidal crises” with sudden swelling and pain in the haemorrhoids and are left with skin tags and haemorrhoids extending from inside to outside.

At Brisbane Colorectal, we perform an excisional haemorrhoidectomy under general anaesthetic in the operating theatre, using an energy device called a “Ligasure”. This has been shown to result in a quicker, less painful operation compared to traditional excisional haemorrhoidectomy. Most patients spend one night in hospital, but some patients go home on the same day if the surgery is done in the morning and they are comfortable after the operation. We insert a “pudendal nerve block” which is a nerve block using long-acting local anaesthetic at the beginning of the operation to numb the area and this often can last even for 2-3 days to improve the initial pain after the operation. Not uncommonly, patients will have little to no discomfort until the nerve block wears off.

Excisional haemorrhoidectomy has been shown to be the most effective treatment for haemorrhoids in terms of long-term success. The rate of return of haemorrhoids is the lowest with this operation. The down-side is it can be a painful operation – with discomfort/pain lasting usually 1-2 weeks, the worst discomfort is usually with the first bowel motion. We routinely prescribe painkillers for patients to have at home, along with laxatives and antibiotics (also shown to reduce pain). Most patients find the operation quite tolerable and very rarely do patients need further haemorrhoidal surgery after this operation.

The wounds heal usually by 2-4 weeks and most patients can return to work in one week (often a small pad is required inside the underwear if there is any leakage of fluid from the wounds). Risks of the operation include excessive pain, and delayed bleeding. Urinary retention occasionally happens and infection and faecal leakage are rare.

STAPLED HAEMORRHOIDECTOMY:

Stapled haemorrhoidectomy is an alternative surgical procedure designed to address haemorrhoids. It involves excision of tissue – but rather than the actual haemorrhoidal tissue being excised, a stapled haemorrhoidectomy involves excision of some of the inner lining of the rectum above the haemorrhoids. This causes some scarring which helps to “pull the haemorrhoids back inside”. The operation is performed in the operating theatre under general anaesthesia and a circular stapler is used to excise part of the rectal “mucosa”. It is a relatively quick procedure and is tolerated quite well, with generally minimal discomfort or pain. The maximal effect can sometimes take some weeks to be achieved as the haemorrhoids are “pulled” inside.

Your surgeon can explain the specific risks of this procedure with you. Stapled operations carry a very small rate of longer-term problems but are generally tolerated well.

Haemorrhoidal Artery Ligation and Rectoanal Repair (HAL-RAR):

Another procedure for haemorrhoids is the haemorrhoidal artery ligation and rectoanal repair. This operation is also performed under general anaesthetic and is performed inside the rectum, above the haemorrhoids themselves. It involves a suture used to tie off some of the blood vessels supplying the haemorrhoids, and a running suture used to pull the haemorrhoids and prolapsing anal tissue back inside. This results in shrinkage of the haemorrhoids and a return of the haemorrhoids to their usual position inside the anus. The main advantage of the procedure is that it is very well tolerated, with minimal side effects and can be done as day surgery. Discomfort is usually minimal and the risk of bleeding is also very low. It can be repeated if haemorrhoids recur at a later time. Patients with smaller haemorrhoids or anal ectropion “the anus turning inside out” can benefit most from this procedure. A discussion with your surgeon will determine if this option is suitable for you. For more information see haemorrhoidinfoservice.com.au

INJECTION SCLEROTHERAPY

Injection sclerotherapy is rarely used in Australia for haemorrhoids, but is more common in the United Kingdom. This involves an injection of a “sclerosant” material into the submucosal plane at the level of the haemorrhoids. The sclerosant causes scarring, leading to shrinkage of the haemorrhoids and less stretch. Generally we reserve this treatment for patients who are unable to stop anticoagulant medication or who suffer from “portal hypertension” (elevated pressures in the abdominal veins) with rectal bleeding.

HAEMORRHOIDAL ENERGY THERAPY (HET)

HET is a new minimally invasive technique for treating symptomatic internal haemorrhoids – bleeding, minor prolapse, mucus seepage and irritation/itching of the perianal skin. The HET bipolar system is inserted into the rectum and low power energy is delivered to the blood supply feeding the enlarged haemorrhoids – not to the haemorrhoid itself. This causes the blood volume to be reduced and the haemorrhoid to shrink in size. The low powered energy causes gentle heating of the tissues to 55 degrees – enough to cause reduction in blood supply (thrombosis) but no tissue damage. It is a simple treatment which can be completed within half a minute.

Similar to haemorrhoids banding, the procedure is performed in the endoscopy suite at the Mater Private Hospital, where an anaesthetist will provide sedation. This keeps you asleep, comfortable, and unaware of the procedure being done. Our experience with this new procedure has been very promising, with minimal or no discomfort, only a small risk of minor post-procedure bleeding, and good resolution of symptoms.