Piles - Haemorrhoids in Pregnancy | Dr N Layyous

Piles - Hemorrhoids in Pregnancy

Normally there are numerous blood supplies with arteries and veins to the anal and rectal area which has important role in regulating bowel motion, and controlling stool incontinence through protecting anal sphincter from being exposed to high pressure, (15 % of anal closure pressure at rest is contributed by these blood vessels).

There are some blood vessels in that area called sinusoids; they differ from arteries and veins, in that they don’t have muscles tissue in their walls. This set of blood vessels with the connective tissue and smooth muscle are called hemorrhoid plexus.

Under normal circumstances, these plexuses are not palpable. If there’s an increase in the pressure in anal area or intra-abdominal this would cause them to dilate and become tortuous and eventually be palpable.

It is a common problem, it is estimated that half of the population by the age of 50 years, may have one of the symptoms caused by hemorrhoids.

Causes of Piles - Hemorrhoids:

The conditions that may lead to increase pressure and dilatation of these vessels (hemorrhoids) include the following:

• Pregnancy: enlarging uterus causes increase pressure on these veins.
• Straining caused by chronic constipation.
• Straining during bowel movement.
• Prolonged sitting on the toilet.
• Obesity.
• Liver cirrhosis liver failure or chronic liver disease.
• Aging as the supporting connective tissue weaken with age.
• Lack of exercise.
• Nutritional factors (low-fiber diet).
• Increase intra-abdominal pressure caused by ascetic, intra-abdominal mass, prolonged straining or pregnancy.
• Genetic factor.
• Rare factor is related to absence of valves in hemorrhoid veins.
• Prostate hypertrophy in male patient makes them more prone to Piles - Hemorrhoids.
• Anal intercourse.

Types of Piles - Hemorrhoids:

There are two types of hemorrhoids according to their anatomical position

• Internal Piles: Hemorrhoids which are located in the lower rectum above the dentate line they lack pain receptors.
• External Piles: Hemorrhoids located under the skin around the anus covered by endoderm and skin which are sensitive to pain and temperature.

Internal Piles - Hemorrhoids are subdivided into four grades according to the degree of prolapse:

• Grade 1: No prolapse just prominent dilated and tortuous blood vessels.
• Grade 2: They become prolapsed with bearing down but spontaneously become reduced.
• Grade 3: Prolapsed only with bearing down but you need to do manual reduction to be reduced.
• Grade 4: In this grade Piles - Hemorrhoids become irreducible.

Symptoms of Piles - Hemorrhoids:

Hemorrhoid symptoms usually depend on their location. The most common sign and symptom of hemorrhoids is painless bleeding either fresh after having bowel movement or streak of blood on toilet paper.

• Painless bleeding, usually bright red rectal bleeding.
• Rectal pain:
  • For internal hemorrhoid, as mention before they have pain receptors but if they swell and prolapse they might get strangulated with anal sphincter muscle or if their blood supply is cut off.
  • For external Piles - Hemorrhoids they become painful if thrombosis pain will usually resolve in 2-3 days but the swelling may take few weeks.
• Peri anal mass: Feeling of a lump at anus which is either a prolapsed internal hemorrhoid or a skin tag from thrombosis or dilated skin over external Piles - Hemorrhoids.
• Anal itching and irritation when a hemorrhoid protrudes it can collect small amount of mucous and microscopic stool particles that may cause irritation.
• Mucous discharge.
• Fecal incontinence

Diagnosis of Piles - Hemorrhoids:

Diagnosis is usually done by history and simple physical examination visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids.

A rectal exam may be performed with rectal examination. The doctor might need to insert a gloved lubricated finger into the rectum trying to feel for masses. He might also use small lighted scope to look inside the anal canal or distal rectum (endoscopy) which is performed as an office procedure that doesn’t need sedation depending on past medical history, medications and stability of the patient treatment may follow with further testing.

Things you should pay attention to

Rectal bleeding is never normal although most of the time is due to hemorrhoids but other serious conditions might be the cause.

• If rectal bleeding is associated with marked changes in bowel habit.
• If passing black tarry stool.
• If there is associated abdominal pain hemorrhoids doesn’t cause pain in the abdomen.
• If there is family history of colorectal cancer.
• If the patient age is above 50 year old.
• If there is significant blood loss causing anemia.
• If the patient is taking anticoagulation.

Differential Diagnosis of Piles - Hemorrhoids:

• Rectal polyp.
• Anal fissure.
• Fistulae.
• Abscesses.
• Rectal varices.
• Colorectal cancer.
• Inflammatory bowel diseases.
• Diverticular disease.
• Angiodysplasia.
• Anal warts might be mixed with skin tags resulting from external hemorrhoids.
• Rectal proplase.

Management of Piles - Hemorrhoids:

The most important is preventive and conservative management if conservative management failed or complications happened .then surgical intervention should be done.

Conservative Management of Hemorrhoids:

• Add more fiber to daily diet; food containing fiber such as (lettuce, fiber con, Metamucil) will avoid having constipation which intern will lessen the pressure on the rectum and anus.
• Increase fluid intake at least 8 cups of water.
• Stool softeners it may help but if hemorrhoids are present liquid stool may cause inflammation and infection of the anus.
  
  The above three points help in decreasing the pressure on hemorrhoid ,decrease bleeding inflammation and reduce the irritation from small bits of stool that are trapped around the blood vessels.
• Exercise is helpful in relieving constipation and decreasing pressure even brisk walking 20-30 minutes a day can help stimulate bowel function.
• Individuals should be encouraged to have a bowel movement as soon as possible after the urge arises, if it pass, stool can become constipated and straining with a bowel movement may occur .
• Warm baths, for the buttock and hips can relive itching irritation and spasms of sphincter muscles, 15-20 minutes sitz bath after each bowel movement and two times a day in addition is recommended.
• Try to avoid sitting for long period of time or may benefit from sitting on air or rubber dount available in most pharmacies.

Medication for Piles - Hemorrhoids:

Over the counter medication such as topical creams containing local anesthetic to sooth pain.

Creams and suppositories containing hydrocortisone are also effective but they shouldn’t be used for more than a week at time because they can cause the skin atrophy.

Surgical treatment of Piles - Hemorrhoids:

• Coagulation by either infrared, laser or bipolar which depend on using heat causing small bleeding eventually hemorrhoid hardens and shrivel; this method has few side effects but high recurrence rate.
• Sclera therapy: Injecting a chemical solution into the hemorrhoid tissue to shrink it, it has little or no pains but not that effective.
• Rubber band ligation: the most common used procedure in the united states in which small elastic band is placed around the base of a hemorrhoid to shrink and the surrounding tissue to scare as it heals holding the hemorrhoid in place.
  
  It takes 2-4 procedures done 6-8 weeks a part to completely eliminate the hemorrhoid. Complication are rare, it include mild pain or tightness, bleeding and infection.
• Hemorrhoidectomy : A surgical procedure done under local or general anesthesia where the whole hemorrhoid is removed.
• Staples: It is the newest surgical technique in which the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoid to prolapse is removed it is less painful than traditional hemorrhoidectomy and patients usually return earlier to work.

Regardless of the surgery sitz baths and dietary suggestion for increase roughage are recommended.

Dr Najeeb Layyous F.R.C.O.G

Consultant Obstetrician, Gynecologist and Infertility Specialist