Hemorrhoidal disease

What is hemorrhoidal disease?

Hemorrhoidal disease is nodular enlargement, inflammation and dysfunction of the blood vessels (veins) in the lower rectum and anus.

Hemorrhoidal disease is divided into four grades depending on the degree of prolapse of the hemorrhoidal nodes (Figure 1):

• Grade 1 – enlarged internal hemorrhoidal veins;
• Grade 2 – internal hemorrhoidal veins prolapse through the anus during defecation and then reduce spontaneously (return to their previous anatomical position);
• Grade 3 – internal hemorrhoidal veins prolapse through the anus during defecation and then require manual assistance (with a finger) to be reduced;
• Grade 4 – permanent prolapse of the internal hemorrhoidal veins.

What are the symptoms of hemorrhoidal disease?

The most common symptoms are pain in the anal canal, bleeding, itching, discharge from the rectum and irritation of the perianal skin, and formations near the anus that cause aesthetic and hygienic complaints. Hemorrhoidal disease most often presents as episodic exacerbations. As a result of a prolonged disease course, complaints may be persistent.

What contributes to the development of hemorrhoidal disease?

Several factors contribute to its development:

• bowel movement disorders – chronic constipation, prolonged sitting on the toilet, severe straining during defecation, infrequent bowel movements;
• lifestyle – prolonged sitting, a sedentary lifestyle and lack of physical activity;
• diet – insufficient fluid intake, low dietary fibre intake, excessive consumption of spicy foods or alcohol;
• increased intra-abdominal (abdominal cavity) pressure – pregnancy, childbirth, obesity, frequent lifting of heavy objects, disproportionate physical exertion, chronic cough;
• age and tissue changes – connective tissue weakness, changes in vein wall elasticity;
• other factors – genetic predisposition (heredity), chronic liver diseases.

How is hemorrhoidal disease diagnosed?

Diagnosis of hemorrhoidal disease is based mainly on clinical assessment, but it is also important to exclude other, more serious pathologies (for example, colorectal cancer). The diagnosis is established by performing a perineal inspection, digital rectal examination (finger examination) and proctoscopy (examination of the mucosa of the anal canal and rectum with an instrument) (Figure 2). The examination is not painful and also enables identification of other possible causes of the complaints.

What complications can hemorrhoidal disease cause?

A prolonged course of hemorrhoidal disease is associated with the development of several complications:

• chronic bleeding resulting in anaemia (low blood count);
• thrombosis of a hemorrhoidal vein;
• perianal dermatitis, i.e. skin inflammation (caused by constant moisture in the anal area);
• an increased risk of developing an anorectal abscess (suppuration).

Hemorrhoidal disease does not increase the risk of developing rectal cancer. However, it should be remembered that prolonged attribution of symptoms to known hemorrhoidal disease often delays timely diagnosis of colorectal cancer, because the presence of one pathology does not exclude another.

What is the treatment of hemorrhoidal disease?

Treatment of hemorrhoidal disease is complex and varied. The choice of treatment is determined by the grade of hemorrhoidal disease, the nature and duration of complaints, and existing risk factors.

Depending on the individual situation, it includes:

• correction of risk factors – most often correction of bowel habits, diet and lifestyle;
• pharmacological therapy – prescribed in cases of acute inflammation or first manifestation of the disease;
• surgical treatment – in situations where conservative therapy does not provide treatment effectiveness.

There are several invasive treatment options (procedures and operations) used in hemorrhoidal disease:

• local methods – sclerotherapy or ligation of the internal hemorrhoidal veins; these are office-based procedures and do not require anaesthesia;
• laser-surgical methods – HeLP and LHP procedures. Minimally invasive surgical treatment methods aimed at occluding blood vessels (hemorrhoidal arteries or veins);
• occlusion of afferent vessels under Doppler guidance and correction of mucosal prolapse – the THD and HAL-RAR methods;
• stapled hemorrhoidopexy, or the Longo procedure – excision of a flap of rectal mucosa and submucosa with the aim of reducing prolapse of the mucosa and internal hemorrhoidal nodes from the anal canal, as well as reducing the blood supply to the hemorrhoidal nodes;
• conventional hemorrhoidectomy – excision of altered skin and mucosal areas (internal and external hemorrhoidal nodes) using various types of energy devices.

The method of surgical treatment for hemorrhoidal disease is determined by the physician based on the patient's complaints, objective findings, the intended surgical goal and the characteristics of the postoperative period.

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