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Hemorrhoids

Definition


Hemorrhoids are essentially dilated blood vessels, mostly veins that develop over the course of years in response to having bowel movements. When humans defecate they sit down on the toilet and push after taking a breath and closing their airway (Valsalva maneuver). The Valsalva maneuver increases the pressure inside the abdomen and pelvis which pushes the blood in the rectal veins into the anus. The veins fill with blood and, over the course of years, dilate. As the hemorrhoids develop the anal lining swells and protrudes into the anal canal. During BM’s the hemorrhoids get pushed towards the outside along with the stool. As they enlarge and develop, the inner or internal hemorrhoids may travel to the point where they are actually protruding outside from the anus. It is the pushing, swelling, and movement of the inner rectal lining that cause most of the symptoms associated with hemorrhoids. There are two types of hemorrhoids, internal and external. To understand the difference between internal and external hemorrhoids you must learn a little about the anatomy of the anal canal.


Anal Anatomy and Internal and External Hemorrhoids


The anal canal is about 1 to 2 inches in length and has 2 types of lining. The external lining is a specialized type of skin while the inner lining is rectal mucosa (pink in color and the type of lining found throughout the rectum and colon). The juncture of these two surface linings is in the middle of the anal canal (called the dentate line). Hemorrhoids are classified as being either internal or external based on what type of lining lies over them. If there is skin covering the hemorrhoidal veins they are external and if there is pink rectal mucosa overlying them they are internal hemorrhoids. It is important to note that most hemorrhoids have both internal and external parts (called a mixed hemorrhoid). Having said this, there are patients who have either internal or external hemorrhoids alone. The symptoms patients experience depend very much on the type of hemorrhoids they have (internal, external, or mixed internal/external).


Thrombosed External Hemorrhoids


These very annoying and painful hemorrhoids tend to occur “out of the blue” and to last for 1-2 weeks only. In response to straining or having a BM the external hemorrhoid swells with blood. For some reason the veins that supply the external hemorrhoid do not allow the blood filled hemorrhoid to empty. It is believed that the vein thromboses (clots) which prevent blood flow. The arteries feeding the hemorrhoid continue to pump blood into the hemorrhoid which increases the swelling. Eventually, the veins burst and then the blood forms a clot. The localized swelling usually is purple and looks like a grape or marble has been slid under the skin. The Thrombosed hemorrhoid stretches the anal skin overlying it which results in pain. The pain is constant and not related to BM’s. Having a BM does not make the pain worse or better. Eventually, if left alone, the hemorrhoid either spontaneously bursts, which relieves the pressure and lessens the pain, or is slowly resorbed which also decreases the swelling and the pain. Eventually, the swelling and the symptoms resolve. What is left in most patients is an asymptomatic skin tag. It is believed that external hemorrhoids cannot recur at the same location. Unfortunately, a new one can develop at another site around the anus.


Treatment of Thrombosed External Hemorrhoids


What is done for these painful hemorrhoids depends on when the patient is seen by the surgeon. If seen at a time when the pain is at its peak or increasing (usually within the first 3-5 days) then a simple surgical procedure, done in the office, is the best option. After administering a local anesthetic, a small incision is made over hemorrhoid and the blood clot removed. This relieves the pressure and the pain. The skin incision causes some pain afterwards; however, it is much less painful than the Thrombosed hemorrhoid early in its course


If the patient is not seen by a doctor for a week or more after the onset of symptoms, most often, the symptoms have begun to decrease. The hemorrhoid may have spontaneously ruptured or started to resolve. The swelling may still be present and obvious, however, the pain is usually notably less and decreasing daily. If this is the situation then surgical incision should be avoided since, at this point, the pain from the surgical incision will likely be worse than the residual pain from the resolving hemorrhoid. Sitz baths, stool softeners, and non-steroidal analgesics such as Tylenol or advil are the best treatments at this point.


Internal Hemorrhoid Symptoms


Chronic, BM to BM symptoms and development.


Hemorrhoid Classification: Internal Hemorrhoids are classified in regards to the extent to which they move and remain outside the anus (prolapse) during and after a bowel movement (BM). Grade 1 hemorrhoids do not appreciably prolapse during a BM. Grade 2 hemorrhoids briefly prolapse outside the anus but then immediately return to their regular position. Grade 3 hemorrhoids prolapse during a BM and have a tendency to remain outside the body for a period of time. If left alone, they will eventually slide back into the rectum. Most people learn to push them back inside (“reduce”) with a finger or by sitting down on a hard surface after the BM. Grade 4 hemorrhoids remain prolapsed outside all of the time and will not stay inside when pushed back inside. When the inner rectal lining is continually exposed to the external environment it may become thicker and take on a different color. These “metaplastic” changes can be easily recognized by a colorectal surgeon and are not dangerous in regards to the development of a cancer.


Surgical Treatment of Hemorrhoids


Introduction


There are two basic surgical methods used to treat hemorrhoids: the standard hemorrhoid excision and the stapling method. Surgery is usually used only for Grade 3 or 4 hemorrhoids (hemorrhoids that prolapse outside the anus during a bowel movement and require a push or a long period of time before they go back inside, however


Traditional Hemorrhoid Excision


This method is usually used for patients with mixed internal and external hemorrhoids. Each hemorrhoid group is removed (while preserving the anal sphincter and most of the anal lining) after which the wounds are closed with absorbable sutures. See below for more details of the procedure.


Hemorrhoidal Stapling


This method is best suited for patients with symptomatic internal hemorrhoids (most common symptoms are bleeding and prolapse) although it can also be used for patients who have large internal hemorrhoids and smaller external hemorrhoids. There is less pain associated with the stapling method and patients require less pain medications than traditional hemorrhoidectomy patients. With this method, part of the internal hemorrhoids and rectal lining close to the anal sphincter is removed with a staple gun that is inserted into the anal canal. There are no external incisions, sutures, or staples with this method. Hemorrhoidal stapling takes place in the operating room (same as the traditional hemorrhoidectomy method).


Holding Area / Consent


The patient will be admitted to the hospital in the Ambulatory Surgery area and an intravenous line placed. Either in the Ambulatory Surgery area or outside of the operating room both the surgeon and the anesthesiologist will speak with the patient, review the surgical and anesthesia options, and obtain consent from the patient. The patient will then be taken to the operating room.


Anesthesia Options


Patient Positioning


The patient will be turned and placed face down lying on his stomach. A bolster (a pillow or rolled sheet) is placed under the patient’s pelvis to elevate the anorectal area. In addition two smaller bolsters are placed under the chest between the breast and the shoulder on each side. The buttocks are gently taped to the side of the table to expose the anorectal area. The anorectal area will be prepared with a soap solution to kill the bacteria on the skin. The anal canal and hemorrhoids will be examined after which the operation will be started.


Standard Excisional Approach


Usually there are 3 separate hemorrhoids to be dealt with (right anterior, right posterior and left lateral). A solution of saline and dilute epinephrine is injected into the hemorrhoid before the dissection is begun in order to reduce the bleeding during the removal. The anoscope will be positioned and an inverted “V” shaped incision made at the outer edge of the hemorrhoid (see Figure 15-7). The first goal is to identify the anal sphincter muscle and to carefully dissect it away from the hemorrhoid. Once the muscle has been fully protected and the hemorrhoid fully elevated a thin oval shaped piece of the hemorrhoid is excised (see figure 15-8). The edges of wound and the remaining hemorrhoid are then elevated off of the muscle (to protect the muscle) which creates a flap after which the hemorrhoid tissue is excised from the flap while preserving the anal skin and the rectal surface lining (see figure 15-11). The hemorrhoids lie beneath the surface lining but above the anal muscle layer. The hemorrhoid can be excised without damaging either the anorectal lining or the muscle below it (this is called a submucosal resection). After the hemorrhoid has been fully excised, if there is bleeding it is stopped with hemocautery (electrical current used to coagulate the bleeding vessel) or a suture. Next the two edges of the wound are sutured together starting at the base of the wound (furthest inside the anal canal) and progressing towards the outer edge of the anus where the suture is tied. An absorbable running suture (over and over suture) material is used that does not need to be removed. The wound is fully closed in this manner (see Figure 15-13).


The same procedure will be carried out for each of the patient’s hemorrhoids. Usually, a total of 3 areas are resected (rarely 4). For the final 1 or 2 hemorrhoids, usually the smallest, a fully submucosal method may be used. In this method, after injecting the epinephrine solution, a linear incision is made along the long axis of the anal canal (about 4 to 6 cm in length). The sphincter muscle beneath is located and the hemorrhoid dissected away from the muscle (in order to protect the muscle). Next, the hemorrhoid is cut away from the flap but all of the surface lining is preserved. This is different from the above method in which an ellipse of anal lining is excised along with a portion of the hemorrhoid. After the hemorrhoid has been fully removed hemocautery is again used to stop any bleeding that may be present. The resulting wound is then suture closed using an absorbable suture.


At the end of the operation all suture lines are inspected and a local anesthetic is injected into the anal area for postoperative pain relief. A gauze dressing is then placed over the anus and held in place with mesh underwear or tape. The patient is then turned onto his back (from the face down position) and woken up by the anesthesiologist.


In this operation the anal muscles are fully protected and preserved. Also, great care is taken to ensure that the anal skin lining is adequately preserved. None of the nerves supplying and running to the anus are cut or injured in this operation


Postoperative Care


Three types of pain medication will be used: 1) flagyl, 2) toradol (ketorolac), and 3) vicodin (or percoset). Flagyl (metronidazole) is an antibiotic that has been shown to significantly decrease the amount of pain experienced by hemorrhoidectomy patients. The flagyl is taken for 3 to 4 days in total. A total of 3 flagyl pills are taken each day. Toradol is a very strong non-steroidal anti-inflammatory drug (NSAID) that is taken by mouth 4 times a day for 3 days. The toradol is an excellent pain medication for intestinal and anal operations because it is strong and doesn’t contain narcotic. Narcotics can be taken; however, they slow down intestinal motility and can lead to constipation. The last pain medication that is given, when the toradol and flagyl together are not providing adequate pain relief is vicodin. Vicodin is a mixture of narcotic and Tylenol that is very effective.


When the patient no longer requires narcotics (usually 3 to 5 days after surgery) but still wants some pain relief then ibuprofen (advil) 600 mg will be taken every 4 to 6 hours as needed. Ibuprofen does not cause constipation and is a very effective pain medication.


In addition to the above pain medications, the following medications are taken to soften the stool and prevent hard stools and constipation. Metamucil or any other psyllium seed or cellulose based fiber additive (such as konsyl, or citricel), is taken 1-2 tablespoon per day. The second medication that is taken is colace (docusate sodium) 100 mg, three times a day for 3 weeks. Finally, mineral oil, 1-2 tablespoons per day, is taken daily for 2-3 weeks.


One of the most important postoperative treatments is the sitz bath. A sitz bath is a plastic basin that fits inside a toilet (with the seat up). Warm water is run into the basin during after which the patient sits in the basin for 10 minutes. This submerges the anal area and all of the incisions in the warm bath. This cleans and sooths the area. It is advised that the patient take 3 to 4 sitz baths a day for the first week and also to take a sitz bath after all bowel movements. This removes all stool debris and is soothing to the area. An alternative to the sitz bath is the bidet. The bidet washes the anal area with warm water and accomplishes the same things. If a bidet is available and preferred then it can be used instead of the sitz bath.


A regular (solid food) diet is started the day of surgery although many patients decide to drink fluids only initially. Hot and spicy food is avoided for the first 2 weeks, if possible. If the patient has a poor appetite then it may take a few days before they have desire for or will tolerate the regular diet. Clear fluids can be taken until solids are tolerated.


Walking is encouraged on the day of surgery and afterwards. Walking is not dangerous and, in fact, can help the patient to recover.


First Bowel Movement


It is important to understand that there is no danger to the success of the operation if the patient has a bowel movement at any time after the surgery. Therefore, if the patient has the urge to have a bowel movement they should evacuate. The patient should not “put off” or delay a bowel movement thinking that it will cause a problem. If the patient feels the urge at any time he should sit on the toilet and attempt to have a bowel movement. There is no danger in pushing to bring about evacuation. However, the patient should also understand that although not, in any way, dangerous, the bowel movements are painful during the first week after surgery.


In order to eliminate the need to have a bowel movement during the first few days after surgery patients are encouraged to take a laxative the night or day before the operation in order to empty out most of the colon (not a full preparation as was needed for the colonoscopy). If the colon is mostly empty before the operation then they will probably not need to have a bowel movement on the first or second days after the surgery. Dr. Whelan recommends taking 10 ounces of magnesium citrate liquid the night before surgery.


If the patient has not had a bowel movement 72 hours after the operation then he will be given 2 to 3 tablespoons of milk of magnesia by mouth. If there is no BM within 6 hours then an additional 3 tablespoons of milk of magnesia will be given. If 6 hours later the patient has not had a bowel movement then 4-6 ounces of magnesium citrate will be given to the patient. This combination of laxatives will bring on a bowel movement.

What Our Patient’s Say…


Our family wishes to express our heartfelt appreciation for the kindness, excellent care and wisdom our mother, Jean Broussard, received during her hospitalization.

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