Rubber Banding Ligation is recommended as the initial mode of therapy for hemorrhoids

Hemorrhoids are the most common anorectal disorder in the Western World and are a major cause of rectal bleeding. Many treatment options have been proposed and tried for early-stage hemorrhoids. There is general agreement that Rubber Banding Ligation (RBL)is safe and effective.

A method that could restore anal cushions to their normal size and position would be naturally preferred to methods that destroy tissue and interfere with the mechanisms of continence. Nonoperative treatment is recommended for patients with symptoms caused by grade 1 to 3 hemorrhoids. Rubber Banding Ligation (RBL) is recommended as the initial mode of therapy for hemorrhoids of grade 1 to 3.

This study confirms that the technique is quick, safe and effective in our population. The mean time required for onesession was 6.2 min; the longest was 10 min.

No major complications were noted. Minor early and late bleeding reported, but none was severe. Pain occurred in 6.7%, but was not severe.Urinary retention may occur in 10% to 50% of patients after surgical hemorrhoidectomy. There were no episodes of urinary retention or sepsis in tested group.

The Biology of Hemorrhoids (also known as Haemorrhoids)

Hemorrhoids (American English), Haemorrhoids (British English) also known as emeroids or piles are a swelling and inflamation of the veins of the rectum. Hemorroids can develop from two different places: either internal rectal veins which can become swollen and will form internal hemorrhoids. But, as the internal structure of the rectum has few pain receptors these cannot generally be seen or felt. External rectal veins can also swell to form external hemorrhoids. External hemorrhoids can be seen around the outside of the anus and, many times, can be felt.

The image above shows the rectum and anus. The external sphincter is at the bottom and the internal shpincter is shown by the pectinate line at the top. In this figure A represents an internal hemorrhoid, B represents an external prolapsed hemorrhoid, C is a mixed hemorrhoid (both internal and external), D is a thrombosed hemorrhoid and E is an external hemorrhoid.

As the image above demonstrates, there can be several categories of hemorrhoids:

• External hemorrhoids are those that occur outside of the anal verge (the distal end of the anal canal). They are sometimes painful, and can be accompanied by swelling and irritation. Itching, although often thought to be a symptom from external hemorrhoids, is more commonly due to skin irritation. These occur in a vein of the inferior rectal plexus, below the pectinate line and covered with modified anal skin.
  
• Internal hemorrhoids are those that occur inside the rectum. As this area lacks pain receptors, internal hemorrhoids are usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated. These generally occur in a vein of the superior rectal plexus, originating above the pectinate line and covered by mucous membrane. Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids:
  
• Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they descend below the pectinate line and are pushed outside the anus.
  
• If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid.
  
• A thrombosed hemorrhoid is a hemorrhoid containing clotted blood.
  

Causes

The causes of hemorrhoids are many and varous and include genetic predisposition (weak rectal vein walls and/or valves), straining during bowel movements and pregnancy. It is though that the latter two causes lead to increased pressure in the hemorrhoid veins, thus causing them to swell. It is also though that too much pressure on the rectal veins due to poor muscle tone or poor posture. Liver disease can also cause increased pressure in the veins and also cause hemorrhoids. Anal sex can also stress the anus particularly if too little lubricant is used and cause rectal wall strain. Hemorrhoids are also linked to sitting for prolonged periods of time.

Additional factors that can influence the course of hemorrhoids (mostly by increasing rectal vein pressure), especially for those with a genetic predisposition, are obesity and a sedentary lifestyle. Constipation, chronic diarrhea, poor bathroom habits, pregnancy, postponing bowel movements, and fiber-deprived diet may be associated with bowel movement and straining, but not all of these have been conclusively proved to cause hemorrhoids.

Hemorrhoids are very common and have been estimated to occur in up to half the population by age 50 years.

Using a squat toilet has been hypothesised to reduce straining and therefore reduce the occurrence of hemorrhoids. However, the medical research into this subject is scarce, and there has been no definite proof for this hypothesis. It is true that hemorrhoids are very rare in nations where people squat to defecate but this epidemiological argument doesn't necessarily prove a causal relationship as there may be unresolved genetic factors at play.

Dehydration can cause a hard stool or chronic constipation which can lead to hemorrhoidal irritation. An excess of lactic acid in the stool, a product of excessive consumption of milk products such as cheese, can cause irritation and a reduction of consumption can bring relief. Vitamin E deficiency is also a common cause.

Western diets may also have a part to play in that excessive alcohol or caffeine consumption can cause diarrhea which in turn can cause hemorrhoidal irritation.

Prevention

Prevention of haemorrhoids is difficult, particularly if you have a genetic disposition. Thoug there are certain things you can do to help alleviate (and if lucky eliminate) the problem in the long term. Pro-biotic yoghurts and drinks may be of use as these help maintain colonic health. Also drinking more fluids, eating more dietary fiber, exercising, practicing better posture, and reducing bowel movement strain and time are also preventative measures. Hemorrhoid sufferers should avoid using laxatives and should strictly limit time straining during bowel movement. Wearing tight clothing and underwear will also contribute to irritation and poor muscle tone in the region and promote hemorrhoid development. Indeed, Some sufferers report a more comfortable experience without underwear or wearing only very lightweight panties, etc.

Straining during bowel movements can be lessened by defecating in a standing position, knees slightly bent. This position seems to use the muscles of the abdomen to expel feces preventing a strain on the anus. Fluids emitted by the intestinal tract may contain irritants that may increase the fissures associated with hemorrhoids. Washing the anus with cool water and soap may reduce the swelling and increase blood supply for quicker healing and may remove irritating fluid. Kegel exercises for the pelvic floor may also prove helpful.

Examination

It is estimated that 85% of the world's population will be affected by hemorrhoids at some time in their life but only a tiny percentage of sufferers actually seek medical treatment and those tend to be at the extreme end of sufferers.

After visual examination of the anus and surrounding area for external or prolapsed hemorrhoids, a doctor would conduct a digital examination. In addition to probing for hemorrhoidal bulges, a doctor would also look for indications of rectal tumor or polyp, enlarged prostate and abscesses.

If warranted, more detailed examinations, such as sigmoidoscopy and colonoscopy can be performed. In sigmoidoscopy, the last 60cm of the colon and rectum are examined whereas in colonoscopy the entire bowel is examined.

Treatment

Treatments for haemorrhoids vary from the 'leave alone and hope for the best' to increasing options in terms of cost, risk and effectiveness. It is also true that different cultures and individuals approach treatment differently.

The truth is that no treatment will prevent hemorrhoids. However, it is possible to alleviate the symptoms and reduce the progression of the disease.

Indeed, for many people hemorrhoids are a mild and temporary condition that heals spontaneously or by employing some of the measures discussed above for the alleviation of the disease. It is also true that local treatments such as warm sitz baths, using a bidet, extendable showerhead, cold compress, or topical analgesic (such as Nupercainal), can provide temporary relief. Consistent use of medicated creams (such as Anusol and Preparation H) during the early stages of a hemorrhoid flare-up will also provide relief and may stave off further development and irritation. However, creams containing steroid preparations weaken the skin and may contribute to further flare-ups. It is essential, however that you maintain the affetcted area dry and clean and use some lubrication provided by hemorrhoidal creams or a lubricant, such as Surgi-lube or petroleum jelly. Suppositories designed for hemorrhoid sufferers can also aid in releiving symptoms.

In terms of natural treatments Horse Chestnut extract (also known as Aesculus hippocastanum) can be effective in that it contains a saponin known as aescin, that has anti-inflammatory, anti-edema, and venotonic actions. Aescin improves tone in vein walls, thereby strengthening the support structure of the vein.

Topical application of vitamin E applied twice-daily to the affected area has also been reported to be effective for some individuals.

However, if the haemorrhoids are severe clinical intervention will be required. The various kinds of treatment include:

• Rubber band ligation Here elastic s are applied onto an internal hemorrhoid to cut off its blood supply. Within several days, the withered hemorrhoid is sloughed off during the course of a normal bowel movement.
  
• Hemorrhoidolysis/Galvanic Electrotherapy which involves desiccation of the hemorrhoid by the application of an electrical current.
  
• Sclerotherapy A sclerosant (a hardening agent) is is injected into hemorrhoids, which causes the vein walls to collapse and the hemorrhoids to shrivel up.
  
• Cryosurgery Here the frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues. This treatment is hardly used these days due to damage caused because of the destruction of surrounding tissues.
  
• Laser, infrared or BICAP coagulation Here a laser, an intense infrared beam or a high-tension electrical current is used to cauterize the affected tissues.
  
• Hemorrhoidectomy This is a true surgical procedure where the hemorrhoids are literally excised or cut out. One drawback of this surgical technique is that it may be associated with incontinence later in life.
  
• Stapled Hemorrhoidectomy This is a procedure generally applied only to prolapsed hemorrhoids where it is designed to resect soft tissue proximal to the dentate line, which disrupts the blood flow to the hemorrhoids. It is generally less painful than complete removal of hemorrhoids and also allows for faster recovery times.
  
• Doppler Guided Hemorrhoidal Artery Ligation Interestingly, this is the only evidence based surgery for all grades of hemorrhoids. It does not involve cutting tissues or even a stay at the hospital; patients are usually back to work on the same day. It is the best treatment for bleeding piles, as the bleeding stops immediately.