External Hemorrhoids:

Definition

The external hemorrhoids are a network of vessels under the skin just outside the anal opening. When a blood clot develops inside one of these vessels it is said to be thrombosed and causes the overlying skin to swell suddenly. The hallmark of this condition is a hard marble-shaped, often blue in color, lump at the edge of the anal opening. It is usually moderately to severely painful.

Causes

Thrombosed hemorrhoids often occur with chronic constipation, diarrhea, after a period of heavy lifting or exercise, or during pregnancy. Often there is no identifiable event that led to the thrombosis.  The clot can cause enough tension on the skin that it may erode through the skin and lead to sudden, rather disconcerting bleeding.

Symptoms

Symptoms include a painful external lump, acute onset, purple in color.

Diagnosis & Treatment

If left untreated, the thrombosis will eventually resolve on its own.  The swelling will go down and the pain will subside, but this may take a few weeks to completely resolve.  The most efficacious treatment is excision of the clot under local anesthetic.  The doctor will examine the area first to determine the size of the swelling and the status of the thrombosis. If it is judged that the worst of the pain is already over or the clot has already eroded through the skin, the surgeon may recommend simple evacuation of the remaining clot or conservative treatment with warm baths and a low dose anesthetic ointment.  If the patient is still in acute pain at the time of the examination, then excision of the external hemorrhoid vein and its clot is usually recommended. Simply lancing the skin to relieve the pressure is ineffective and the swelling will often recur after the blood clots again. To excise the hemorrhoid, a tiny needle is used to inject numbing medicine and then the skin over the clot is removed along with the clotted hemorrhoid. This is not a full hemorrhoidectomy:  The wound is left open and will heal on its own over the next week or two. A dressing is placed over the wound; it is normal to have some slight bleeding after the procedure.

Internal Hemorrhoids:

Definition

A hemorrhoid is a vascular cushion of tissue in the lining of the anal canal. Everyone has three internal hemorrhoids. When these hemorrhoids become enlarged, they may cause painless rectal bleeding. Swelling of the hemorrhoid may cause it to prolapse (slide out) during a bowel movement.  The prolapsed tissue may go in on its own, but if the hemorrhoids are very large, the patient may need to push them back in manually.  The swelling and prolapse can lead to leakage of mucus and fecal matter and cause anal discomfort, itching or burning.  Unless the hemorrhoids are thrombosed or massively swollen, they usually do not cause intense pain.  Severe, acute anal pain is more likely due to an anal fissure or abscess.

Diagnosis

Many patients come in or are sent to us because they are thought to be having hemorrhoid problems. Upon evaluation by our surgeons, approximately one third of these patients are found to have a diagnosis other than hemorrhoids as the root cause of their symptoms.  We frequently see patients who have been repeatedly treated by ‘hemorrhoid relief centers,’ but upon examination, have a different problem entirely. This is why it is imperative that each patient be thoroughly examined at the time of their initial evaluation. The skin around the anus and the opening of the anal canal are carefully inspected to be sure there is no other pathology, such as a fissure or fistula which could account for the patient’s symptoms. A digital rectal exam will be performed to determine the presence or absence of tenderness or any palpable growth.  Next, an anoscope (a short instrument to allow the inside of the canal to be inspected) is inserted and the size, location and characteristics of the hemorrhoid tissue are determined. If the patient has been having rectal bleeding, a longer scope (a proctoscope) may be inserted to be sure there are no other lesions in the rectum that could be the underlying cause of the bleeding.

Treatment

After an examination, the surgeon will discuss the findings and explain the treatment options.  Most patients with hemorrhoid problems benefit from increasing the amount of fiber in their diet.  Taking a fiber supplement such as Benefiber, Metamucil or Citrucil is an additional way to increase daily fiber intake.  For patients with very mild symptoms, this may be all that is needed.  Sometimes a low dose a steroid suppository or ointment is prescribed.  However, by the time many patients seek care from us the hemorrhoids are large enough that an additional procedure will be required to relieve the patient’s symptoms.  Fortunately, the overwhelming majority of patients can be treated with office based procedures that require neither surgery nor anesthetics.  Your doctor will explain these to you.  The most commonly utilized treatments are:

  • Barron ligatures (rubber bands) — A rubber band is put around the hemorrhoid, causing it to wither and fall off over a seven- to ten-day period.  This typically consists of a series of treatments during which a single hemorrhoid is treated at each session.
  • Infra Red Coagulation — A light source is used to burn the surface of the hemorrhoid, causing it to stop bleeding and shrink down to normal size. Although all the hemorrhoids can be treated at once, the procedure may need to be repeated once or twice for greater effect, and is best used for small or flat bleeding hemorrhoids.
  • Injections — A liquid is injected into the hemorrhoid, stopping the bleeding and preventing it from protruding.  This is a less frequently utilized modality than the first two options.  It may require repeat injections.

All of these options are available and are performed on a daily basis at Fairfax Colon & Rectal Surgery.  These treatments are only used for internal hemorrhoids. They would be extremely painful if used for external hemorrhoids.  These procedures are usually performed at your next office visit after you have had the opportunity to discuss treatment options with your doctor.  These procedures are typically not painful because the manipulation is done inside the canal where there are minimal pain nerve fibers. The main discomfort is from the anoscope which is inserted to expose the tissue during the procedure.  Each procedure takes just a few minutes to accomplish.  Remember that bleeding and prolapse may persist until all the hemorrhoids and prolapsing tissue have been treated. There is no preparation or fasting needed for these procedures; patients can expect to be able to drive themselves home afterwards.

Surgical Treatment of Internal Hemorrhoids

The majority of patients with complaints attributable to hemorrhoids can be managed without having to resort to an operation. However, an operation may be needed if the hemorrhoids are either too large (internal), external or  they have additional anal pathology,  thus not amenable to office based procedure

There are two main operations performed for hemorrhoids: formal hemorrhoidectomy or a Doppler Guided Hemorrhoid Artery Ligation.  The hemorrhoidectomy procedure is much more common than the second procedure.

A formal hemorrhoidectomy consists of removing the external and internal hemorrhoids. This is done withone, two or three separate incisions depending on the extent of the patient’s hemorrhoid problem.  Once the tissue is removed, sutures are used to repair the anal canal; these are absorbable stitches and will not need to be removed later.

The operation typically performed in an outpatient setting with deep sedation and local anesthetic.  The patient remains asleep the entire operation and will not sense any discomfort during the surgery. This operation has been proven highly effective for relieving the patient’s hemorrhoid problems for the long term.  The early down side on the surgery is that the post-operative period can be very painful.  Patients need to anticipate at least a two-week recovery at home during which they need to do frequent sitz baths, take the pain medications prescribed, and remain on stool softeners and fiber supplements for easier passage of their bowels.

The Doppler Guided Hemorrhoid Artery Ligation procedure is particularly useful in patients whose primary problem is prolapse and bleeding of their internal hemorrhoids (the hemorrhoids protrude and do not go back in easily) with external hemorrhoids. This operation utilizes an ultrasonic Doppler probe which is inserted into the anal canal to locate the position of the main arteries feeding the enlarged hemorrhoid tissue. The arteries are then tied off with sutures and the excess hemorrhoid tissue is sutured into its normal position within the anal canal. This cuts off the blood flow to the hemorrhoid and restores normal anatomy. It does not, however, remove the hemorrhoids. It is not particularly useful for patients with substantial external hemorrhoids or skin tags.

This is also an outpatient operation and utilizes the same type of anesthetic as the standard hemorrhoidectomy. The advantage of this operation is the degree of pain experienced and the rapidity of recovery. Although it is by no means a painless operation, in most cases it is associated with significantly less pain than the standard hemorrhoidectomy. Many patients are able to return to normal activity within 2-3 days following surgery. It has proven to be an effective treatment for hemorrhoids but because it is a relatively new operation, the risk of recurrence in fifteen or twenty years is unknown.

Since most patients have both internal and external hemorrhoids, the standard hemorrhoidectomy remains the most commonly performed operation.  The surgical options and potential risks will be discussed with you during the consultation with the surgeon.

Visit the American Society of Colon & Rectal Surgeons website for more information