Clinical and alternative aspects for treatment and management of hemorrhoids.
“Hemorrhoids are swelling and inflammation of veins in the rectum and anus. The word ‘hemorrhoid’ itself refers to ‘cushions of tissue filled with blood vessels at the junction of the rectum and anus.”
Talking of hemorrhoids, we have to differentiate between external hemorrhoids and internal hemorrhoids. Internal hemorrhoids can be found inside of the rectum. They are considered to be varicosities of veins which drain those areas which are serviced by the superior rectal arteries. Internal hemorrhoids normally do not cause any pain, because these areas do not show any pain receptors. This is also the reason why internal hemorrhoids most of the time go unnoticed, unless some degree of irritation occurs and they start to bleed, or they become distended, which will push them out of the anus, thus becoming visible. In this case, we talk of “prolapsed hemorrhoids.” Additional problems occur when a spasm of the anal sphincter entraps those prolapsed hemorrhoids at the anus. The result will be a cutoff of the entire blood supply, and we talk then of “strangulated hemorrhoids. “ Internal hemorrhoids can be categorized into 4 grades, which are:
Grade 1: No prolapse of hemorrhoids.
Grade 2: Prolapse upon defecation with spontaneous reduction.
Grade 3: Prolapse upon defecation with the need of manual reduction.
Grade 4: Prolapse without the possibility of manual reduction.
External hemorrhoids, on the other hand, become visible outside of the anal canal. They are also varicosities of veins, but these veins drain different areas. Since the veins, affected by internal hemorrhoids, relate to the superior rectal arteries, external hemorrhoidal veins relate to the inferior rectal arteries. Another important difference to internal hemorrhoids is, that the external counterpart usually is very painful. They also show the tendency to induce or develop thrombosis in case of a ruptured vein. Once the external hemorrhoidal vein developed blood clots, it is becoming a thrombosed hemorrhoid. We talk of a thrombosis when blood clots or thrombi settle inside the vein and reduce blood flow in the affected area. These thrombi have possible life-threatening potential. If they break loose and travel to other organs and reduce their blood supply, we talk of a heart attack or myocardial infarction if it happens in the coronary system of the heart; a stroke if it happens inside the brain; an embolism if it occurs inside the lungs etc.
What are the diagnostic signs of suffering from hemorrhoids?
Since internal hemorrhoids do not cause any pain, they will only be uncovered when they start to bleed. In this case, light red blood can be observed on stool, toilet paper, or in the toilet bowl. External hemorrhoids are painful and show up as swellings or hardened lumps in the anus area. The adverse situation can aggravate by excessive straining, cleaning, rubbing etc. of the anus, which induces additional irritation, like bleeding and itching.
What are the causes for hemorrhoids?
The development of hemorrhoids is the result of several different conditions. Long-term constipation, but also diarrhea, is usually accompanied by excessive straining during defecation. This excessive straining is known to be a prominent reason for the expression of hemorrhoids. Extended constipation will occur when the liquid intake is below average, forcing the large intestines to withdraw more water from the stool than normal. This results in a more compact and hardened stool, which is much harder to expel. Women with premenstrual syndrome and menstruation can experience constipation due to increased water retention, thus have a higher chance to develop hemorrhoids.
Hypertension has also shown to be a triggering factor for the development of hemorrhoids. In this case, it is not the systemic or essential hypertension, which marks to be the culprit, it is the portal hypertension, which shows some potential regarding this matter. The reason for this is, that one end of the portocaval anastomoses ends in the rectal wall. If the pressure rises in the portal veins, the blood becomes stagnant and dilates the afferent veins in the rectal area, leading to the expression of hemorrhoids.
Obesity very often triggers hypertension and also diabetes, which can also result in an elevation of venous pressure in the rectal area. This can be aggravated by a weak muscle tonus and poor posture.
Pregnancy is also known to be a possible cause for hemorrhoids if the patient develops pregnancy-induced hypertension (preeclampsia) and exerts increased strain during defecation. As mentioned earlier, insufficient liquid consumption over a longer period of time will very likely develop into chronic constipation due to the hardening of the stool.
Some sorts of food are also known to trigger hemorrhoids, as there are yogurt and similar diary products with high concentrations of lactic acid. Suffering from vitamin E deficiency is also regularly associated with hemorrhoids.
A more unusual, “funny” reason was reported by Dr. Berko Sikirov. He detected a correlation between the manifestation of hemorrhoids and the application of sitting toilet bowls. In his study from 1987 he tried to proof the hypothesis that the regular use of squatting toilets is a kind of treatment and cure from hemorrhoidal problems. The connection between “sitting” and “squatting” seems to be unclear at first sight, but his findings showed that 18 out of 20 probands experienced a total relief from their symptoms, like bleeding and pain. This result was observed to be maintained also for the following 30 months after the end of the study. Statistically 20 probands are not sufficient to be able to claim any relevance. The study yet is of some value, since it took a very interesting look into a “non-medical”, “non-pharmacological” direction, which might really be more helpful for the patient than ever expected. Unfortunately, a similar study with a bigger amount of patients had never been initiated. Nevertheless, it seems to be a kind of “public secret” that squatting, instead of sitting, in using the toilet, has some preventive value towards the development of hemorrhoids.
It’s only hemorrhoids, so what? - Possible consequences if left untreated
As we have seen earlier, external hemorrhoids bring on some degree of discomfort, pain, itchiness, and possible bleeding, during bowel movement and during the rest of the day. The discomfort and the suffering are most of the time strong enough to make the patient go and ask for medical assistance, thus taking care of his problem. Internal hemorrhoids are much trickier, since neither discomfort, nor pain, nor related negative sensations can be noticed, because of the lack of pain receptors in this area. Only bright red blood spots on his stool will reveal their presence to the patient.
The question now is, if the patient decides to do nothing about his problem, what possible long-term consequences are waiting for the hemorrhoids owner? Both patients, the one with his internal and the one with his external hemorrhoids, show more or less extended tissue destruction in the rectoanal area. The bypassing excrements contain large amounts of microorganisms, which increases the possibility of an infection dramatically. The onset of an infection in this area provides therefore additional discomfort, and left untreated, the infection becomes chronic, which will be paired with an inflammation in this area and associated changes of environment in the entire affected area. A long-term inflammation executes a negative impact on neighboring areas as well, so that we can expect some impact especially on the sphincter function and its decrease, which marks the beginning of a condition, called incontinence.
If we take a look at the external hemorrhoids, since these hemorrhoids provide more or less pronounced discomfort for the patient, chances for ignoring them by their carrier are comparatively low. Additionally these kind of hemorrhoids show more often the tendency of being strangled, ultimately shutting down the blood supply in these veins. In combination with the buildup of blood clots after some period of time, perfusion in the central and in the neighboring areas is greatly diminished, thus ensuring that the problem gets worse. These blood clots, deriving from external hemorrhoids, have most probably easy access to systemic blood vessels. This will increase the likelihood for those thrombi being passed on into the systemic blood circulation and forming emboli. As we discussed earlier, an embolus is a thrombus which migrates through the circulatory system from one organ to another. If it reaches vital organs like brain, kidney, heart, lungs, it could impact negatively the hemodynamic situation in those organs to a point, where large tissue areas a cut off their blood supply, which results in organ failure and ultimately death of the affected person.
Another possible scenario shows up when long-term external hemorrhoids become gangrenous. Wikipedia defines gangrene in the following way: “Gangrene is a complication of necrosis (cell death) characterized by the decay of body tissues, which become black (and/or green) and malodorous. It is caused by infection or ischemia, such as by the bacteria Clostridium perfringens or by thrombosis (blocked blood vessel). It is usually the result of critically insufficient blood supply (e.g., peripheral vascular disease) and is often associated with diabetes and long-term smoking.” On top of this, the necrosis shows very often the tendency to infiltrate neighboring areas and turn them also necrotic. Thus the gangrene is not only maintaining its status, it is also growing and expanding, increasing the unphysiologic conditions for the patient.
Since the long-term effects of unattended, untreated hemorrhoids can reach devastating dimensions, there is no argument being left for the patient, not to look for professional help in the treatment and cure of his condition.
Some thoughts about the cure and more thoughts about the prevention of hemorrhoids
An old proverb, deriving from the traditional Chinese medicine, states, that one ounce of prevention weighs more than one pound of cure. In our case, nothing seems to be more true than this, making prevention a much easier task than the cure.
The most important requirement for a successful prophylaxis of hemorrhoids is a regular and sufficient intake of fluids every day. Sufficient is usually completely different for two different persons, especially if person 1 executes a lot of physical activities, paired with increased perspiration, and person 2 works all day long in office setup without lots of physical activities. But not every “fluid” is qualified for hemorrhoid prophylaxis. The best fluid to use is plain water. Soft-drinks, for example, contain high amounts of sugar, which increase the osmotic pressure in the vessels, which results in a withdrawal of water from the neighboring tissues and from the large intestines. The final result is a dryer and also firmer stool, which looses mobility, which urges the person to executive intensified strain, the first step towards the development of hemorrhoids.
In addition to this, the consumption of dietary fibers is almost as important as sufficient fluid intake. Vegetables, fruits, fiber enriched cereals, for example, have the capacity to keep the stool soft. As additional bonus, these fibers seem also to have the capability to prevent cancer of the large intestines. They provide nutrients for certain bacteria, which reside in this part of the GI tract. Their primary role is the support of absorption of various nutrients, vitamins, etc., and they take care of a balanced status of the GI tract, which diminishes the possibility of the development of cancer.
Another preventive measure was already discussed earlier. A lot of physicians recommend squatting instead of sitting during defecation. Although we don’t have conclusive statistical material about this question, only the earlier mentioned study with only 20 probands, it seems that this recommendation has been generally accepted for the treatment and prevention of external and internal hemorrhoids.
The symptomatic therapy
The buildup of hemorrhoids is often accompanied by emission of fluids from the anal orifice. These fluids contribute to the increased irritation of the hemorrhoidal area, thus worsening the discomfort and pain. A possible consequence can be the enlargement of the existing hemorrhoids and the buildup of additional hemorrhoids. In order to prevent an aggravation of the situation, it is highly advisable to clean the anus with cool soap water, which will reduce possible swelling. Having contained the swelling, blood supply will be more likely enhanced, which promotes better healing capacities and takes away many of the usual symptoms.
Yet there are additional strategies to get along with the symptoms. Sitz baths, for example, and hydrotherapy with warm water are highly recommendable. The effect of the warm water is that the affected vessels in the anal and rectal area will dilate, which ultimately improves the perfusion in the area. For pain control one can use topical or systemic analgesics. Other regimen apply vasoconstrictors, moisturizers, astringents, and cortisone products, the last one taking care of the accompanying inflammation.
Severe cases have to be treated by surgical intervention. There exist a couple of techniques for the removal of hemorrhoids: Hemorrhoidolysis, hemorrhoidectomy, cryosurgery, sclerotherapy, rubber band ligation, transanal hemorrhoidal dearterialization (THD-HP), Doppler guided hemorrhoidal artery ligation, stapled hemorrhoidectomy, etc.
The natural treatment
Coming from the hemorrhoids’ prevention chapter, one cannot stress enough the importance of preventive measures. These measures cannot only prevent the buildup of hemorrhoids, but they are also able, to a great amount of cases, once applied and introduced into the regular life of the patient, to improve the patient’s condition without any additional medication. On the other hand, should symptoms persist, this will be the time when to think about consulting a physician. Recurring or remaining symptoms, pain, etc. in this case could be a symptom for a more severe underlying disease, which must be excluded by diagnosis. For example, some other, more severe conditions, might be confused with suffering from hemorrhoids, like rectal cancer, anal fissures, abscesses, fistula, perianal hematoma, etc. Leaving these condition untreated will spell for severe trouble.
A somewhat different approach lies in the strengthening and stabilization of the blood vessel walls and additionally to fight the inflammation. Vitamin P, also known as citrin or bioflavonoids, are known to be very effective in this regard. Flavonoids can be found in practically most of the plants. They are responsible for plant pigmentation and are part of a plant’s defense mechanism against microorganism, fungi, and insects. For humans and animals, who eat them, they have shown to exert “health-modulating effects.” Research has proven, that those flavonoids have strong antiallergic, antiinflammatory, antibiotic, and anticarcinogen potency. Other beneficial properties are positive effects on diarrhea, vasoprotective properties, and improvement of rheologic conditions, which results in an improved perfusion of organs, especially the heart.
Citrus fruits are the primary source of those flavonoids, as well as berries, gingko biloba, onions (red onions), tea (green tea), red wine, dark chocolate with a 70% and higher cocoa content.
Ayurveda offers a compound of three fruits, called triphalangia, which improve bowel tonic, thus resolving softly any constipation without the possible side effects of over stimulation. For topical use, calendula and/or chamomile do usually a great job.
There are more possibilities of applications deriving from the western alternative and herbal medicine in the treatment of hemorrhoids. its Chinese counterpart offers acupuncture for the same purpose. In acupuncture predefined points on certain meridians will be treated with the help of needles, thus reducing discomfort and pain. This kind of treatment has to be repeated for several times to take full effect and to ensure that no relapse will occur in the future. Ear acupuncture and moxibustion are other complementary approaches in hemorrhoids therapy.
Herbal Chinese medicine has also to offer powerful herbal remedies, yet those herbs applied have to be carefully selected by a knowledgeable and well-trained person, a specialist in Chinese herbal medicine. The advantage of those herbal solutions, be it western or eastern style, is that only minor side effects are to be expected.
In terms of herbal Chinese medicine, we can resort here to very effective remedies. Unfortunately, these regimen are not suited for a “do-it-yourself” treatment, since the herbs have to be carefully chosen by herbal doctors with experience and sufficient training. Overall the advantage of therapeutic approaches by the western herbal medicine and its eastern counterpart lies definitively in the fact that we have to expect only a limited amount of side effects. In terms of long-term safety they usually are showing better records than the western school medicine.
General factors, which help to reduce the possibility for the development of hemorrhoids, are clothing which is not too tight and sufficient physical exercise.
Cauda
If the hemorrhoid patient observes these rules in terms of liquid intake, accompanying measures, like exercise, squatting during bowel movement etc., proper dietary behavior, chances are high that the prevention and treatment of hemorrhoids is not hard to manage and success will be setting in in a short period of time.