On 26 October, Medical Academic and Anusol presented a webinar on the management of haemorrhoids (also known as piles). The webinar was presented by Dr Peter Barrow.
One in two people will complain of symptomatic piles at some point during their lifetime. It is also one of the most Googled medical conditions. Haemorrhoids are little vascular channels that surround the anal sphincter.
One of the most important things to define when initiating haemorrhoid treatment is whether the haemorrhoids are internal or external. Internal haemorrhoids develop from the inferior haemorrhoidal venous plexus situated above the dentate line and are enveloped by mucosa. In contrast, external haemorrhoids are swollen venules within this plexus located beneath the dentate line, and they are coated with squamous epithelium.
GRADING SYSTEM
It is important to determine the type of haemorrhoid because they behave very differently. Internal haemorrhoids tend to bleed, whereas external haemorrhoids thrombose and may cause severe pain. Internal haemorrhoids are further subdivided into four grades of severity, based on the extent of prolapse that is occurring.
“Grade I internal haemorrhoids have no prolapse. These patients usually show up at a practice complaining about rectal bleeding,” Dr Barrow said. “Grade II is when haemorrhoids prolapse briefly after straining while passing stool, but then reduce themselves spontaneously. Some patients with Grade II haemorrhoids might not even be aware of it.” “Grade III haemorrhoids protrude constantly and need to be pushed back into the anus manually. Finally, Grade IV haemorrhoids are irreducible haemorrhoids which permanently protrude. While Grade III and IV haemorrhoids seem like they are external haemorrhoids, they occur above the dentate line.” Haemorrhoids tend to cluster in particular sites within the anal canal. When viewing the anal canal when the patient is in a supine position, one will find that haemorrhoids tend to occur at 3 o’clock (left lateral), 7 o’clock (right posterior) and 11 o’clock (right anterior).
PATHOGENESIS
“Patients always want to know ‘Where does my haemorrhoids come from?’” Dr Barrow said. Increasing age is a risk factor for haemorrhoids, as is any condition that causes straining when passing stool. “This includes not only constipation but also chronic diarrhoea, and in fact any condition that causes frequent visits to the toilet,” Dr Barrow said. Childbirth and pregnancy could also cause piles, due to increased abdominal pressure and decreased venous return, which increases the venous pressure around the haemorrhoidal veins. Perhaps the most surprising risk factor, however, is prolonged sitting, and especially sitting for long periods on a toilet seat.
“Diet is also extremely important as a risk factor and a lot of patients will approach you for info on this,” Dr Barrow said. “Unfortunately most doctors don’t really know how much fibre, for example, there is in common foods. Instead, we say something generic like ‘Eat more vegetables and fruits.’”
Want to know more about the amount of fibre in common food types? How do lifestyle changes impact haemorrhoids? What’s the rubber band for? For answers to these and other questions, please watch a recording of this webinar here: https://vimeo.com/webinars/events/8af07f62-1db7-4440-a176-1fe5abad55d7. Please note that this webinar is NOT CPD-accredited.
