haemorrhoids-and-other-perianal-disease

Haemorrhoids And Other Perianal Disease

 

Haemorrhoids are a very common condition that affect  more than 50% of people by the age of 50.

This condition is usually caused by constipation that leads to excessive straining on bowel movement. It can be precipitate by childbirth, excessive coughing or abdominal distention.

Haemorrhoids are also called piles, they are swollen veins in the anal canal and lower rectum, similar to varicose veins. Haemorrhoids may result from straining during bowel movements or from the increased pressure on the veins during pregnancy. Haemorrhoids may be located inside the anal canal (internal haemorrhoids), or they may appear as redundant  and stretched skin folds of the perianal region (external haemorrhoids).

Symptoms:
1. Bleeding
2. Swelling around the anus
3. Difficulty to clean the area after a bowel motion
4. Occasionally, a clot may form in a haemorrhoid (thrombosed haemorrhoid); these can be very painful and may need to be drained.
5. Itching
6. Mucous discharge
7. Pain and discomfort
Causes:
The veins that drain blood from the anus tend to stretch under pressure and may bulge or swell. Swollen veins (haemorrhoids) can develop from increased pressure in the lower rectum due to:

1.Straining during bowel movement

2. Sitting for long periods of time on the toilet

3. Chronic constipation

4.Overweight

5. Childbirth

6.Low-fibre diet

7.Straining during urination

8. Heavy lifting

Occasionally excessive bleeding can lead to anaemia, excessive straining or lifting of a heavy object can lead to protrusion and strangulation of haemorrhoids that is a painful condition

Medical Treatment:
The best treatment is prevention by a high fibre diet, adequate hydration, avoiding excessive straining on the toilet and avoiding prolonged sitting. If constipation remains a problem you can use a fibre supplement, there are many options available over the counter.

If you have painful prolapsed haemorhoids the following measure are very useful

  1. Salt bath three times a day
  2. Icepacks
  3. Laxatives
  4. Bed rest
  5. Pain killers
  6. Soothing ointment, available over the counter

There are many options available to treat haemorrhoids.

Treatment:

  • High-fibre foods; Fruits, vegetables and whole grains usually are effective to soften the stool and increases its bulk and that helps to avoid the straining. Supplemental stool softeners can also be used
  • Soothing ointments; over-the-counter haemorrhoid ointment or suppository that have hydrocortisone and a local anaesthetic.
  • Salt bath; three times a day for 10 to 15 minutes is very helpful
  • Moist toilet paper; to help keep the anal area clean after a bowel movement
  • Ice packs; apply ice packs or cold compresses to relieve swelling and the pain.
  • Oral pain killers; Panadol and Ibuprofen temporarily to help relieve your discomfort.

With these measures, haemorrhoid symptoms often settle down within about ten days.

Surgical Treatment:

You need to discuss with your doctor the option of surgery if there is excessive bleeding, pain, excessive discomfort or the presence of a lump

  • Rubber band ligation; Rubber bands placed around the internal haemorrhoid to cut off their blood supply. They fall off within a week to ten days. This procedure is effective to control bleeding and reduce swelling. Haemorrhoid banding can be uncomfortable and may cause bleeding
  • Injection (sclerotherapy); In this procedure, your doctor injects a chemical solution into the haemorrhoid tissue to shrink it.

 

  • Surgical Excision; This is the most effective treatment for removal of large protruding haemorrhoids, in particular those with an external component. The operation is performed under general anaesthesia. The patient is expected to stay in the hospital for 2-3 nights. The operation is associated with significant pain because the anal skin is very sensitive.
  • Recovery: The patient will require pain killers, stool softeners, salt baths and adequate rest; you will expect to resume normal activities in 2-3 weeks, but pain may persist for four weeks. Some bleeding is expected for the first few weeks.
  • Complications of Surgery:

1.Urinary Retention

2. Excessive pain

3. Bleeding

4. Infection is a rare complication that may require antibiotics

5. Recurrence in the form of skin tags usually that can be uncomfortable, true recurrence of internal haemorrhoids usually due to excessive internal haemorrhoids that can not be removed in the original operation

6. Excessive scarring could lead to anal stenosis (narrowing of the anal canal) which may require further surgery.

After the operation if there is excessive bleeding, pain or you are feeling unwell or have a temperature you will need to consult with your doctor.

Perianal fistula and abscess

This is a relatively common condition and can affect patients at any age. This occurs due to the presence of perianal mucous secreting glands, that normally drain inside the anal canal; if the duct gets blocked the gland gets infected. Patients with diabetes are particularly at risk of having this infection

Symptoms:

  1. Intense perianal pain
  2. Swelling around the anal region, which is of sudden onset and throbbing
  3. Feeling unwell
  4. Fever

Treatment:

You need to report to an emergency department for assessment if you have the above symptoms. The diagnosis is clinical by examination, occasionally MRI or CT scan might be needed.

You will need to start having intravenous antibiotics and your surgeon will take you to the operating theatre to drain the pus under general anasthesia. The wound will be left open and needs packing until it heals from the base.

Recurrence is relatively common, which can be as an abscess or formation of a fistula.

Anal Fistula:

This is also a common condition, it means a communication between the inside of the anal canal and the the perianal skin. It manifest as intermittent pain followed by yellow or purulent or blood stained discharge . This is associated usually with feeling a lump in the perianal region. The symptoms are low grade and intermittent so the condition is less urgent than an abscess and usually goes on for months before the patient consults with their doctor; it may happen after drainage of a perianal abscess.

Treatment:

The definitive treatment is surgery. The type of the procedure depends on the type of the fistula. In order to determine that you might need to have a MRI of the area; you may need other investigations such as endoscopic ultrasound or sigmoidoscopy.

Types:

1. Subcutaneous or submucus type which is simple: The treatment is laying open the fistula track and postoperative packing for a few weeks so it heals from the base of the wound.

2. Intersphincteric: the fistula track passes between the internal and external sphincter. In this situation the treatment is also by laying open the track and packing for a few weeks

3. High inter-sphincteric fistula:

4. Trans-sphincteric fistula

5. Extrashincteric

Image result for anal fistula

Surgical Options:

  • Laying the fistula open. The surgeon cuts the fistula’s internal opening, and drains the infected collection. Fistulotomy may be done in two stages if a significant amount of sphincter muscle is involved.
  • Mucosal flap. The surgeon creates a flap from the inner layer of the  rectal wall, then the internal opening is removed. The flap is then used to cover the repair. This procedure reduces the amount of sphincter muscle that may need removing.
  • Seton placement: The surgeon places a rubber string into the fistula to drain the infection.
  • Fibrin glue and collagen plug: The surgeon clears the fistula track and closes the internal opening. A glue made from fibrin is then injected through the external orifice.
  • Ligation of the inter sphincteric fistula:  This is a two-stage operation for complex fistulas. A seton is inserted into the fistula tract. Several weeks later you will need to have a second stage operation, the surgeon with be able to close the internal opening or cover it with a flap.