PILES (HEMORRHOIDS): MINIMALLY INVASIVE PROCEDURES AND TREATMENT.

Hemorrhoids also called piles, are swollen and inflamed veins in your anus and lower rectum. Hemorrhoids may result from straining during bowel movements or from the increased pressure on these veins during pregnancy, among other causes. Hemorrhoids may be located inside the rectum (internal hemorrhoids), or they may develop under the skin around the anus (external hemorrhoids).

Hemorrhoids are common ailments. By age 50, about half of adults have had to deal with the itching, discomfort and bleeding that can signal the presence of hemorrhoids.

Fortunately, many effective options are available to treat hemorrhoids. Most people can get relief from symptoms by using home treatments and making lifestyle changes.

SYMPTOMS

Signs and symptoms of hemorrhoids may include:

Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet bowl
Itching or irritation in your anal region
Pain or discomfort
Swelling around your anus

A lump near your anus, which may be sensitive or painful
Leakage of feces

Hemorrhoid symptoms usually depend on the location. Internal hemorrhoids lie inside the rectum. You usually can't see or feel these hemorrhoids, and they usually don't cause discomfort.

But straining or irritation when passing stool can damage a hemorrhoid's delicate surface and cause it to bleed. Occasionally, straining can push an internal hemorrhoid through the anal opening. This is known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids are under the skin around your anus. When irritated, external hemorrhoids can itch or bleed. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus), resulting in severe pain, swelling and inflammation.

When to see a doctor
Bleeding during bowel movements is the most common sign of hemorrhoids. But rectal bleeding can occur with other diseases, including colorectal cancer and anal cancer. Don't assume that bleeding is coming from hemorrhoids without consulting a doctor.

Your doctor can do a physical examination and perform other tests to diagnose hemorrhoids and rule out more-serious conditions or diseases. Also consider seeking medical advice if your hemorrhoids cause pain, bleed frequently or excessively, or don't improve with home remedies.

If your hemorrhoid symptoms began along with a marked change in bowel habits or if you're passing black, tarry or maroon stools, blood clots, or blood mixed in with the stool, consult your doctor immediately. These types of stools can signal more extensive bleeding elsewhere in your digestive tract.

Seek emergency care if you experience large amounts of rectal bleeding, lightheadedness, dizziness or faintness.

CAUSES

The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins (hemorrhoids) can develop from an increase in pressure in the lower rectum. Factors that might cause increased pressure include:

Straining during bowel movements
Sitting for long periods of time on the toilet
Chronic diarrhea or constipation
Obesity
Pregnancy
Anal intercourse
Low-fiber diet

Hemorrhoids are more likely as you get older because the tissues that support the veins in your rectum and anus can weaken and stretch with aging.

COMPLICATIONS

Complications of hemorrhoids are rare but include:

Anemia. Chronic blood loss from hemorrhoids may cause anemia, in which you don't have enough healthy red blood cells to carry oxygen to your cells. This may result in fatigue and weakness.
Strangulated hemorrhoid. If blood supply to an internal hemorrhoid is cut off, the hemorrhoid may be "strangulated," which can cause extreme pain and lead to tissue death (gangrene).

PREPARING FOR YOUR APPOINTMENT

If you have signs and symptoms of hemorrhoids, make an appointment with your regular doctor. Depending on your signs and symptoms, your doctor may refer you to one or more specialists — including a doctor with expertise in the digestive system (gastroenterologist) or a colon and rectal surgeon — for evaluation and treatment.

You can help your doctor by being prepared with as much information as possible. Here are some suggestions to help you get ready for your appointment.

What you can do

Be aware of any pre-appointment restrictions. At the time you make the appointment, ask if there's anything you need to do in advance.
Write down any symptoms you're experiencing and how long you've noticed them.
Write down key personal information, including typical bowel habits and diet, especially your fiber intake.
Make a list of all medications, vitamins or supplements that you're taking.
Write down questions to ask your doctor.

Your time with your doctor is often limited, so preparing a list of questions can help you make the most of your time together. For hemorrhoids, some questions you might want to ask your doctor include:

What's the likely cause of my symptoms?
Is my condition likely to be temporary or permanent?
Am I at risk of complications related to this condition?
What treatment approach do you recommend?
If treatments we try first don't work, what will you recommend next?
Am I a candidate for surgery? Why or why not?
Are there any additional self-care steps that might help?
I have other medical problems. How can I manage these along with hemorrhoids?

In addition to the questions that you've prepared, don't hesitate to ask questions as they occur to you during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

When did your symptoms first occur?
How uncomfortable are your symptoms?
What are your typical bowel habits?
How much fiber does your diet contain?
What, if anything, seems to improve your symptoms?
What, if anything, appears to worsen your symptoms?
Has anyone in your family ever had hemorrhoids or cancer of the colon, rectum or anus?
Have you had a change in your bowel habits?
During bowel movements, have you noticed blood on your toilet paper, dripping into the toilet or mixed into your stools?

What you can do in the meantime

In the time before your appointment, take steps to soften your stools. Eat more high-fiber foods, such as fruits, vegetables and whole grains, and consider trying an over-the-counter fiber supplement, such as Metamucil and Citrucel. Drinking six to eight glasses of water a day also may help soften your stools and relieve your symptoms.

TESTS AND DIAGNOSIS

Your doctor may be able to see if you have external hemorrhoids simply by looking. Tests and procedures to diagnose internal hemorrhoids may include:

Examination of your anal canal and rectum for abnormalities. During a digital rectal exam, your doctor inserts a gloved, lubricated finger into your rectum. He or she feels for anything unusual, such as growths. The exam can give your doctor an indication of what further testing might be appropriate.
Visual inspection of your anal canal and rectum. Because internal hemorrhoids are often too soft to be felt during a rectal examination, your doctor may also examine the lower portion of your colon and rectum with an anoscope, proctoscope or sigmoidoscope. These are scopes that allow your doctor to see into your anus and rectum.

Your doctor may want to do a more extensive examination of your entire colon using colonoscopy. This might be recommended if:

Your signs and symptoms suggest you might have another digestive system disease
You have risk factors for colorectal cancer
You're older than age 50 and haven't had a recent colonoscopy

TREATMENTS AND DRUGS

Most of the time, treatment for hemorrhoids involves steps that you can take on your own, such as lifestyle modifications. But sometimes medications or surgical procedures are necessary.

Medications

If your hemorrhoids produce only mild discomfort, your doctor may suggest over-the-counter creams, ointments, suppositories or pads. These products contain ingredients, such as witch hazel or hydrocortisone, that can relieve pain and itching, at least temporarily.

Don't use an over-the-counter cream or other product for more than a week unless directed by your doctor. These products can cause side effects, such as skin rash, inflammation and skin thinning.

Minimally invasive procedures

If a blood clot has formed within an external hemorrhoid, your doctor can remove the clot with a simple incision, which may provide prompt relief.

For persistent bleeding or painful hemorrhoids, your doctor may recommend another minimally invasive procedure. These treatments can be done in your doctor's office or other outpatient setting.

Rubber band ligation. Your doctor places one or two tiny rubber bands around the base of an internal hemorrhoid to cut off its circulation. The hemorrhoid withers and falls off within a week. This procedure — called rubber band ligation — is effective for many people.
Hemorrhoid banding can be uncomfortable and may cause bleeding, which might begin two to four days after the procedure but is rarely severe.
Injection (sclerotherapy). In this procedure, your doctor injects a chemical solution into the hemorrhoid tissue to shrink it. While the injection causes little or no pain, it may be less effective than rubber band ligation.
Coagulation (infrared, laser or bipolar). Coagulation techniques use laser or infrared light or heat. They cause small, bleeding, internal hemorrhoids to harden and shrivel.
While coagulation has few side effects, it's associated with a higher rate of hemorrhoids coming back (recurrence) than is the rubber band treatment.

Surgical procedures

If other procedures haven't been successful or you have large hemorrhoids, your doctor may recommend a surgical procedure. Surgery can be performed on an outpatient basis or you may need to stay in the hospital overnight.

Hemorrhoid removal. During a hemorrhoidectomy, your surgeon removes excessive tissue that causes bleeding. Various techniques may be used. The surgery may be done with a local anesthetic combined with sedation, a spinal anesthetic or a general anesthetic.
Hemorrhoidectomy is the most effective and complete way to treat severe or recurring hemorrhoids. Complications may include temporary difficulty emptying your bladder and urinary tract infections associated with this problem.
Most people experience some pain after the procedure. Medications can relieve your pain. Soaking in a warm bath also may help.
Hemorrhoid stapling. This procedure, called stapled hemorrhoidectomy or stapled hemorrhoidopexy, blocks blood flow to hemorrhoidal tissue. Stapling generally involves less pain than hemorrhoidectomy and allows an earlier return to regular activities.

Compared with hemorrhoidectomy, however, stapling has been associated with a greater risk of recurrence and rectal prolapse, in which part of the rectum protrudes from the anus. Talk with your doctor about what might be the best option for you.

LIFESTYLE AND HOME REMEDIES

The best way to prevent hemorrhoids is to keep your stools soft, so they pass easily. To prevent hemorrhoids and reduce symptoms of hemorrhoids, follow these tips:

Eat high-fiber foods. Eat more fruits, vegetables and whole grains. Doing so softens the stool and increases its bulk, which will help you avoid the straining that can cause hemorrhoids or worsen symptoms from existing hemorrhoids. Add fiber to your diet slowly to avoid problems with gas.
Drink plenty of fluids. Drink six to eight glasses of water and other liquids (not alcohol) each day to help keep stools soft.
Consider fiber supplements. Most people don't get enough of the recommended amount of fiber — 25 grams a day for women and 38 grams a day for men — in their diet. Studies have shown that over-the-counter fiber supplements, such as Metamucil and Citrucel, improve overall symptoms and bleeding from hemorrhoids. These products help keep stools soft and regular.
If you use fiber supplements, be sure to drink at least eight glasses of water or other fluids every day. Otherwise, the supplements can cause constipation or make constipation worse.
Don't strain. Straining and holding your breath when trying to pass a stool creates greater pressure in the veins in the lower rectum.
Go as soon as you feel the urge. If you wait to pass a bowel movement and the urge goes away, your stool could become dry and be harder to pass.
Exercise. Stay active to help prevent constipation and to reduce pressure on veins, which can occur with long periods of standing or sitting. Exercise can also help you lose excess weight that may be contributing to your hemorrhoids.
Avoid long periods of sitting. Sitting too long, particularly on the toilet, can increase the pressure on the veins in the anus.