Having a gut instinct about haemorrhoids

Written after a number of readers have requested that I write about haemorrhoids

Known colloquially as “piles”, the exact incidence of the condition is hard to establish as they are reluctantly brought to a doctor’s attention. This probably explains why studies have found a wide variation in the prevalence of haemorrhoids, ranging from 4.4 per cent of adults in the US, to more than 30 per cent of patients in a UK general practice.

Piles are enlarged vascular cushions within the anal canal. The cushions provide a watertight seal to the anus. When the tissue supporting these cushions weakens, they collapse downwards. The prolapsed cushions interfere with the ability of the veins within them to function; blood then becomes trapped and the cushions become engorged.

The modern classification of haemorrhoids involves a four-degree system: first degree piles bleed but do not prolapse; second-degree haemorrhoids prolapse while passing a bowel motion but then spontaneously return inside the anus: third-degree piles prolapse but require manual reduction to get them back; and fourth-degree piles lie permanently outside the anal canal and cannot be manoeuvred into place.

What disturbs the equilibrium of the vascular cushions in the first place? The degenerative effects of ageing may weaken their supporting tissue. Repeatedly passing a hard bowel motion and straining to defecate exacerbate this weakness. Pregnancy raises pressure inside the abdomen which obstructs the return of blood from veins inside the anal area, meaning that piles are a scourge for many expectant mothers.

Often the first hint that you might have piles is when you notice some fresh blood on a toilet tissue. Alternatively, bright red blood drips painlessly into the toilet bowel. This is a sign that the wall of the haemorrhoid is inflamed and has reacted to the recent bowel motion.

Other common symptoms include anal itching, a mucus discharge or faecal soiling. Severe pain suggests the pile has become clotted with blood.

It is not difficult to diagnose haemorrhoids. Fourth-degree piles will be visible on local examination. A digital rectal examination will detect haemorrhoids at an earlier stage, while a fibre-optic examination of the anal canal using a proctoscope should ensure the accurate diagnosis of first-degree piles.

A word of warning about rectal bleeding in older people. If you are over 40 and especially if you have noticed recent weight loss or a change in bowel habit, it’s best to see your GP to make sure there isn’t a more serious cause.

There cannot be many conditions for which suggested cures include a prayer to St Fiachra, rubber bands and the latest in Doppler-guided technology. Rubber-band ligation was first used to treat haemorrhoids in 1963. Suction banding now allows surgeons to apply up to three bands in a single treatment. Available as an outpatient treatment, up to 80 per cent of patients are satisfied with the short-term outcome.

The latest interventions are Doppler-guided vessel ligation and a stapling procedure involving the excision of a ring of tissue. Specially designed proctoscopes with an inbuilt Doppler probe are used to identify the arteries feeding the haemorrhoids. These vessels are then tied off using absorbable sutures. The circular stapling-gun approach works by reducing prolapsed piles by “hitching” them back up into position.

Most people with piles will not have to face surgical intervention. Eating more fibre has been shown to improve symptoms, as will measures to relieve constipation. Over-the -counter creams containing local anaesthetic, steroids and antiseptics are good at relieving itchiness and local discomfort.

St Fiachra is the patron saint of proctologists and may be worth praying to if you fancy a spiritual approach. He had a reputation in the seventh century as a healer of afflictions of the nether regions.

Dr Muiris Houston at dotMD 2019, Bailey Allen Hall NUIG

by Muiris Houston
This article originally appeared in The Irish Times

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