Haemorrhoids (derived from Greek word “haima” means blood and “rhoos” means flowing) or piles (in Latin “pila” means a ball) refers to dilated veins occurring in relation to the anus.
Hemorrhoids is a common problem. 50% of the people above 50 years of age tend to develop hemorrhoids Haemorrhoids is a Common in both men and women. Disease is the tendency to run in families. Haemorrhoids is Uncommon below the age of 20 years
Structure of Rectum and Anal canal
Rectum is a lowest part of the large intestine (colon). Its a small, straight muscular tube, approx 5” long continues in to the anal canal. Upper part of the rectum acts as a reservoir for stool (contains horizontal mucosal folds known as valves of houston) lower part of the rectum is sensitive to stretch; accumulation of stool in the upper rectum stretches the lower part causing a desire to defecate the stool finally passes through the anal canal and is expelled from the body through an opening called the anus.
Anal canal is 1.5” long extending from anorectal junction to the anus consists of 2 sphincters (muscular valves): internal sphincter (involuntary in nature) and external sphincter (under voluntary control). Both of these sphincters help to keep the stool in the rectum till they can be eliminated. The upper half of the anal canal is thrown into 6-10 vertical folds known as anal columns. At the lower end, anal columns are joined by short horizontal folds called anal valves and these valves together form a horizontal line known as dentate or pectinate line the dentate line demarcates the upper half of anal canal from the lower half
Superior rectal artery mainly supplies blood to the rectum and the upper part of the anal canal (above the dentate line)
Inferior rectal artery supplies the blood to the lower part of anal canal (below the dentate line)
A network of veins called internal rectal venous plexus (haemorrhoidal plexus) lies in the submucosa (the layer below the inner lining or mucosa) of upper half of the anal canal. The tributaries from the plexus drain into the superior rectal vein.
The external rectal venous plexus lies in the lower part of the anal canal at the anal margin and it drains into the inferior rectal vein.
What happens in Hemorrhoids?
Whenever there is increased pressure on superior rectal veins (as due chronic constipation, pregnancy, obesity etc.) the venous drainage is impeded and this causes a back pressure in the internal venous plexus resulting in dilated veins. These are called internal hemorrhoids. The branches of superior rectal vein, located at 3, 7 and 11 o’clock positions in the anal canal are common sites for Internal hemorrhoids. Pressure on the inferior rectal vein (which runs along the anal margin) can cause External hemorrhoids.
Types of Hemorrhoids
Depending upon the site of origin, haemorrhoids can be divided into two types
- External Hemorrhoids
Develops at the margins of the anal opening. They are usually painful because richly supplied by nerves Can be seen outside as a small, tender lump (due to thrombosis)
- Internal Hemorrhoids
Develops inside the anus. They are usually painless because not richly supplied by nerves. Tendency to bulge out of the anal opening in various degrees. When both the external and internal varieties are associated, the condition is called interoexternal haemorrhoids.
Classification of Internal Hemorrhoids
Depending upon the degree of protrusion, the internal hemorrhoids can bedivided into:
- First Degree Hemorrhoids
- Second Degree Hemorrhoids
- Third Degree Hemorrhoids
- Fourth Degree Hemorrhoids
Types of Hemorrhoids
First degree hemorrhoids: The dilated veins remains entirely within the anal canal and do not bulge out of the anal opening.
Second degree hemorrhoids: Piles protrudes during the passage of stool but recede back on its own
Third degree hemorrhoids: The protrusion does not recede back on its own and has to be replaced by hand.
Fourth degree hemorrhoids: Piles may protrude anytime of the day and remains permanently protruded.
What causes Hemorrhoids
The factors, which may be responsible in increasing abdominal pressure resulting into formation of haemorrhoids, include:
- Constant straining due to constipation.
- Diet high in processed food and low in fiber (noodles, cold drinks, fried food, etc.)
- Laxative abuse and frequent enemas.
- Sedentary lifestyle
- Lifting heavy objects
- Repeated coughing and sneezing
- Heredity : Frequently seen in the members of the same family presumably due to weakness of vein walls since birth.
- Pregnancy : Pressure of the fetus in the abdomen cause the blood vessels around the anus to enlarge.
- Some diseases/ conditions such as enlarged prostrate, urethral stricture (narrowing of the urinary opening) and cancer of rectum.
- Occupations involving : Lot of traveling (e.g. marketing and sales professionals) or prolonged standing (e.g. traffic police, waiters, etc.)
Symptoms of Hemorrhoids
Manifestations of hemorrhoids may vary depending upon the type of hemorrhoids
Symptoms of External Hemorrhoids
They may be quite painful as they lie under the skin that has rich supply of nerves.
May appear as a tender blue swelling at the anal margin (due to thrombosis). Since the blood clot usually lies at the level of external sphincter muscles, anal spasm often occurs.
Bleeding and itching in and around anus may also occur in some cases (due to co-existence of internal hemorrhoids, passage of hard stools or poor anal hygiene).
Symptoms of Internal Hemorrhoids
Bleeding while passing the stool may be the only symptom in early stages. The bleeding is bright red in color and occurs as a “splash in the pan”.
Prolapse of hemorrhoids is usually a later symptom. The degree of protrusion depends upon the progress of the disease.
Feeling of vague anal discomfort usually accompanies bleeding. It increases when Piles protrudes through the anal opening.
A mucoid (slimy) anal discharge and fecal leakage usually accompanies prolapsed haemorrhoids.
Itching in and around the anal area follows mucoid discharge from the prolapsed hemorrhoids.
Pain is not a common feature unless complicated by thrombosis (formation of blood clot), infection or erosion of the inner lining of the anal canal (mucosa).