Hemorrhoids are a normal anatomical structure of the anus. They are usually located at the 5th, 7th and 11th hour, with the patient positioned in a gynecological position, but other locations are not excluded. Their physiological function has not been fully understood. They are attributed a protective role (they are considered the “anatomical cushion” of the anus, which prevents injuries to the mucosa from possible descent of hard stools), but they are also involved in the continence mechanism.
Hemorrhoids are characterized as “internal” when they are located above the dentate line of the anus and are covered by epithelium, and as “external” when they are located below the dentate line and are covered by the skin of the anus.
The factors that cause hemorrhoids to suffer are constipation, diarrhea, intense straining during defecation, conditions that generally increase intra-abdominal pressure (e.g. weight lifting, chronic coughing, etc.), pregnancy, age, and genetic factors.
The symptoms of hemorrhoids are:
1. Bleeding. Usually a few drops of blood on the toilet paper or in the toilet, but sometimes it can be significant. In any case of bleeding, other more serious causes of bleeding (e.g. cancer, polyps, diverticula) should always be excluded endoscopically before the loss is attributed to hemorrhoids.
2. Pain. It is not a typical symptom of hemorrhoids, but it can occur in case of thrombosis of hemorrhoids.
3. Palpable mass. Based on this symptom, internal hemorrhoids are classified into 4 categories. First degree, are hemorrhoids that do not prolapse but are mainly manifested by bleeding. Second degree, are hemorrhoids that prolapse during defecation, but automatically subside with the end of it. Third-degree hemorrhoids are those that prolapse during defecation, but return to the anal canal only with finger manipulation. Finally, fourth-degree hemorrhoids are those that prolapse permanently and do not return with any kind of manipulation (image 1).
4. Itching. It is caused by irritation of the perianal skin from the escape of mucus and watery stools.
The diagnosis of hemorrhoids is made by visual inspection and digital examination of the patient. The latter should be avoided during an intense hemorrhoidal attack, because it is particularly painful. Proctoscopy also provides important information, while endoscopic examination of the colon is considered advisable, especially in elderly people, to exclude other more serious causes of bleeding (figure 2).
The treatment of hemorrhoids can be conservative, but also surgical. In the initial stages (e.g. first-degree hemorrhoids that simply bleed), some simple measures may be sufficient, such as increasing the amount of fiber in the diet, consuming more water and fluids in general, treating constipation, avoiding prolonged defecation (the patient should not sit in the pelvis for too long) and avoiding intense straining during defecation.
Another conservative treatment method is the application of the rubber ring. This is a method that is performed with local anesthesia and on an outpatient basis, repeated every 2-4 weeks and involves the capture of hemorrhoids with a special tool and their peribronchialization with a rubber ring, which leads to the cessation of their bleeding and their gradual necrosis and ablation. It is considered an effective method for hemorrhoids, mainly of the second and beginning third degree. Its complications include pain, bleeding, while in rare cases necrotic pelvic inflammation may occur, which begins with pain, fever and urinary retention and should be treated immediately by removing the rubber rings. It is considered a good method, but it has a high recurrence rate (20%-50%).
Conservative measures include cauterization (Image 6). It is mainly indicated for first-degree hemorrhoids that bleed persistently. It involves the application of radiation with a special halogen device that is applied directly to the hemorrhoidal nodule. After treatment, patients complain of pain, but of lesser intensity compared to the application of rubber rings.
Finally, in patients who are immunocompromised, receiving anticoagulant therapy, or who cannot undergo surgery due to serious comorbidities, treatment with sclerosing injections may prove effective (Image 7). Phenol, hypertonic saline solutions, and ethanolamine can be used as sclerosing agents.
Surgical treatment can be done in many ways. One of them is simple hemorrhoid ligation. It was first applied in 1958 and is mainly aimed at immunocompromised patients, or patients who have an increased risk of developing postoperative inflammation. The recurrence rate reaches 13%.
Another method is hemorrhoidectomy. It is indicated for third or fourth degree hemorrhoids, as well as for lower-grade hemorrhoids when conservative treatment has repeatedly failed. It includes the open method (Milligan-Morgan), the closed method (Ferguson), while the excision of hemorrhoids can also be done with some of the modern cauterization devices (Harmonic scalpel, Ligasure). The main disadvantage of the method is the postoperative pain, which can be alleviated with intravenous analgesics and local or oral use of metronidazole. Complications of the method are inflammation, bleeding, anal stenosis, incontinence and recurrence. The overall complication rate is 8.7%, while it has the lowest recurrence rate of all other methods (4%-10%). It is considered the most reliable option, which has been tested over time, has excellent results and is the benchmark for all the newer methods that have emerged in recent years.
In the surgical quiver there is also hemorrhoidectomy (figure 3). It was first applied in 1990, for the treatment of second and third degree internal hemorrhoids. It is a method by which the hemorrhoids are essentially fixed at a higher level, with the help of a special circular anastomosis placed within the anal canal. The advantage of the method is the clearly less postoperative pain, while the disadvantage is the high rate of recurrence. Complications such as bleeding, stenosis, incontinence and chronic postoperative pelvic pain have been reported.
Finally, the surgical options include the Hal method (figure 4). This involves ligation of the vascular stalk of the hemorrhoid with the help of Doppler ultrasound. Thus, the hemorrhoid is deprived of blood supply and gradually shrinks. It is indicated for second or third degree internal hemorrhoids. The advantage is considered to be the lesser postoperative pain. The recurrence rate reaches 11%. There are no studies yet on the long-term effectiveness of the method. This is a method that needs to be tested over time and to prove that it has good results in the long term.
