Hemorrhoids/Fistulas

Hemorrhoids, or piles, are a sometimes painful mass of distended (swollen) veins in the lining of the anus and rectum, resulting from the formation of varicose veins around the anus. Internal hemorrhoids occur at the junction of the anus and rectum and are covered with mucous membrane. External hemorrhoids occur just outside the anus and are covered with skin. On occasion, internal hemorrhoids may prolapse, or protrude, to the outside, cutting off the blood supply. A number of treatments are available for internal hemorrhoids. External hemorrhoids may be treated with local care to relieve pain; if they recur or remain symptomatic they may be surgically removed.

Hemorrhoids can occur at any age, often without apparent cause. A typical scenario for developing hemorrhoids might be someone with a little chronic constipation, who sits for several minutes or more for each bowel movement, often reading a magazine or newspaper at the same time. Repeated straining at stool, over time, causes the encircling dilated veins to gradually stretch and get pushed downward through the anus, ahead of the stool. You might notice that you must wipe several times afterward, and you may be aware of some “extra tissue” protruding through the anus, or note a little trace of blood on the toilet paper. Contributing factors may include severe constipation or diarrhea, pregnancy, liver disorders, rectal tumors, and the repeated long-term use of laxatives. Hemorrhoids can cause itching and burning and may bleed during a bowel movement.

Hemorrhoids do not cause cancer nor do they become cancerous. But any rectal bleeding may be a sign of cancer of the colon or rectum and should be checked by a physician.

Temporary relief from hemorrhoids may be obtained by applying a cold compress directly to the affected area until the pain subsides. This is most easily done if the patient lies face-down and another person applies the compress. Tepid water baths may also help. A person should eat a high-roughage diet to ensure regular defecation of large, soft stools. Ointments, creams, and suppositories containing corticosteroids may also ease the symptoms. In addition to these measures, avoiding constipation is certainly key. It is important to have an adequate amount of fiber in your daily diet. So what do we mean by that? Well, the short answer is to have some sort of bran cereal for breakfast, like All Bran (probably the highest fiber content of the options available), or Raisin Bran, then be sure to include salads and lots of fresh fruits and vegetables in your other meals. You should also drink 6-8 glasses of water or juices per day. Lots of fiber without enough fluids can make the situation worse, similar to the difference between a dry and a wet sponge. The fiber (sponge) can absorb lots of liquid, but without the liquid, the stool will be hard to pass (like a dry sponge).

There’s more detailed information about fiber in the next few paragraphs.

Dietary fiber or roughage is defined as a carbohydrate complex which comes from plants, and it does not get digested in the stomach and small intestine. Since it remains in this undigested state all the way to the colon (large intestine), the remaining fiber absorbs water into the stool, creating bulk and speeds the process by which waste is eliminated from the body.

There are two types of fiber:

• Insoluble fiber doesn’t dissolve in water, and it helps move food through the digestive tract. Whole wheat flour, cereals, pasta, seeds, nuts, green beans, cauliflower, tomatoes, flax seeds, and potato skins contain insoluble fiber.


• Soluble fiber dissolves in water and forms a gelatinous-like material which lowers blood cholesterol and glucose levels. You can find soluble fiber in oats, barley, carrots, broccoli, artichokes, fruits, and berries.

Although dietary fiber has little nutritional value, it has great health benefits. Everyone should be aware of how it can help you lead a healthier life:

• Relieves and prevents constipation. Fiber shortens the transit time of material in the digestive system by absorbing water into the stool, which increases bulk and softens the waste helping it speed along. Constipation and the straining to have a bowel movement are often the causes of hemorrhoids.


• Reduces cholesterol levels. Low-density lipoproteins (LDL), the bad cholesterol, are reduced by soluble fiber. This lowers your risk of developing cardiovascular diseases associated with heart attacks and strokes by preventing the build-up of plaque in the arteries.


• Reduces the risk of digestive conditions. Hemorrhoids, Irritable Bowel Syndrome and Diverticulosis (a disease where small pouches develop in the intestinal walls) are less likely to occur because with fiber the intestinal contractions do not have to work as hard to move the stool along. It is interesting to note that diverticulosis is virtually unheard of in African countries, presumably because of the high fiber content of their diet.


• Regulates blood sugar levels. The absorption of sugar is slowed by soluble fiber which helps prevent type 2 diabetes from forming, and it helps maintain more stable blood sugar levels in those that have diabetes.


• Colorectal cancers may be reduced. Studies are inconclusive but some have shown a reduced number of colorectal cancers in people who eat a high-fiber diet.


• A weight-loss aid. Fiber creates a sense of fullness because high-fiber foods are chewed longer and create more bulk in the stomach. It curbs the tendency to overeat at mealtime, and usually, high-fiber foods contain fewer calories.

Recommended daily amounts of fiber needed by adults according to the National Academy of Sciences’ Institute of Medicine:

Adding more dietary fiber to your meals is one of the nicest things you can do for yourself. If you have hemorrhoids, fiber can work to aid your digestive system in healing and eliminating them.

All cases of rectal bleeding should be examined by a physician to rule out the cancer of the colon and rectum. If the diagnosis is hemorrhoids, the remedies mentioned above may solve the problem. However, persistent hemorrhoids may need to be removed, using one of several methods. Hemorrhoids may be frozen off during cryosurgery; hardened, using a sclerosing agent; tied off, using a rubber band at the base of hemorrhoid; or removed surgically (hemorrhoidectomy). At DeKalb Surgical, the preferred method for most symptomatic hemorrhoids is the rubber band technique, which can be performed as an office procedure.

Hemorrhoids are typically classified according to the amount of prolapse (sticking out) that occurs. Those hemorrhoids which do not prolapse, or which spontaneously reduce (go back inside the anus) can usually be treated in the office setting. At DeKalb Surgical Associates, rubber band ligation is most often used. These small bands are placed over the hemorrhoid tissue, causing them to slowly strangulate and fall off. This treatment can be repeated if necessary. Though some patients experience moderate pain, in most cases, the procedure is tolerated with little discomfort.

Fistulas

A fistula is an abnormal channel from a hollow body cavity to the surface (for example, from the rectum to the skin) or from one cavity to another (for example, from the vagina to the bladder). A fistula may be congenital (bladder to navel), the result of a penetrating wound (skin to the lung), or formed from an ulcer or an abscess (appendix abscess to the vagina, or tooth socket to sinus).

The repeated filling of an abscess or a wound by the fluid contents of some body cavities prevents healing and encourages the formation of a fistula. An anal fistula, for example, begins with inflammation of the mucous lining of the rectum. The area becomes an abscess as it is constantly reinfected by feces; eventually, a fistula breaks through the skin near the anus. The usual treatment is an operation to open the fistula channel completely and drain any abscess so it does not recur.

Anal Fissures

Anal fissures are small tears in the mucus lining of the anal canal. They can occur as a result of the passage of a large hard stool. Fissures can be quite painful, particularly with bowel movements. Often, some bright red blood will be noticed on the stool, or on the toilet paper after wiping.

If you have ever had a painful papercut on your finger, you can understand all about anal fissures. The anus is the ring-like sphincter or valve at the end of your rectum. It relaxes and tightens at your will to allow a bowel movement when convenient. An anal fissure is a small tear in the rim of the anus – just like a tiny papercut.

One problem with a papercut is that every time you use your hands, you tend to break open the small wound, which delays healing and causes more pain. The same holds true with an anal fissure. Every time you have a bowel movement, the anus is stretched and the fissure can possibly be reopened causing more symptoms. This makes some anal fissures chronic and difficult to heal. This problem is quite common and may cause considerable misery.

Fissures will often heal on their own if constipation is avoided. There are some simple measures that can be used to hasten the healing, including the use of stool softeners, and ointments such as Preparation H. Prescription medications may also be used, including a variety of analgesics, and steroid preparations. A more recent treatment option is the use of nitroglycerin ointment, the same type of medication used for patients with angina (heart pain). This medication relaxes the smooth muscle lining underneath the torn mucus layer of the anus. By treating the spasm of this smooth muscle, the fissure will heal in about 85% of cases. However, many patients have headaches as a result of using the nitroglycerin (because it relaxes smooth muscle cells in the arteries to the brain as well).

If the fissure does not heal, a simple outpatient surgical technique, called a lateral internal sphincterotomy, can be used.

The anal canal is anesthetized by injection with a small needle. A small incision is made in the anal canal, and the ring of muscle under the fissure is cut. This relieves the muscle spasm, which in turn allows the fissure to heal. Patients often experience an immediate improvement in their symptoms, though in some cases, the improvement is slower. Potential side effects or complications include temporary incontinence, bleeding, or persistent pain. Incontinence as a complication is unusual, but there may be temporary difficulty in distinguishing between gas, liquid stool, or solid stool in the rectum.

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