Perhaps there is no other
condition that is as often misdiagnosed as hemorrhoids. Both patients and
physicians tend to blame ‘‘hemor- rhoids’’ for a multitude of problems in the
anorectal area, often with dangerous consequences. I have seen many cases where
‘‘hemorrhoids’’ were blamed for the patient’s symptoms and even treated for
years, when the actual pathology was either a fissure, fistula, prolapse, anal
papilla, or in some cases even a carcinoma.
It should be made clear right at the outset that
the diagnosis of ‘‘hemorrhoids’’ should be reached only after confirming the hemorrhoids on visual and anoscopic examination and only after other sources of anorectal symptoms have been excluded. Needless to say, if a proper history is taken and a complete anorectal exam is performed, there should be no difficulty in reaching the correct diagnosis.
As with any other medical condition, diagnosis requires a proper history and a detailed physical examination. A properly taken history and physical exam will not only help make the diagnosis of hemorrhoids but also steer the surgeon towards making the correct treatment choice for a particular patient. In my opinion, the true caliber of a colorectal surgeon can be judged not by his degrees but by the care and expertise he demonstrates in the diagnosis of common anorectal ailments such as hemorrhoids.
History taking should not be considered a menial task delegated to the most junior member of the team. Instead, a thorough and systematic approach should be taken. History should be directed not only towards the symptomatology of hemorrhoids and confirming the diagnosis but also towards excluding other more sinister conditions. In addition, a proper history should assist the colorectal surgeon in making the appropriate decisions for the treatment of hemorrhoids.
The surgeon should inquire about the nature,duration, and severity of symptoms and the extent of discomfort the hemorrhoids are causing. It is also important to get a good idea about what the patient’s expectations are. Certainly a patient who has an occasional asymptomatic prolapse and is otherwise not incapacitated by the disease may not want a painful recovery from an excisional hemorrhoidectomy. Most patients with hemorrhoids have symptoms for a long period of time before they seek medical attention. Often the patients have self-diagnosed the problem and have spent months or even years trying to treat themselves with over the counter medications or ointments. Some patients, however, especially those with a nervous predisposition, present early or even after a single episode of bright red rectal bleeding. While taking the history, the proctologist should focus on the following aspects:
Age: Most patients who develop hemorrhoids are between the ages of 30 and 50. In patients who present at an unusually early age, extra care should be exercised in excluding other diagnostic possibilities such as inflammatory bowel disease, juvenile polyps, polyposis syndromes, etc. On the other hand, in older patients, the diagnosis of carcinoma should always be borne in mind.
Gender: Hemorrhoids occur in both sexes. How ever, pregnancy and childbirth are the prime causes of hemorrhoids in young females. The hormonal milieu of pregnancy, venous congestion, and increased pelvic pressure in late pregnancy and delivery all contribute to the development of hemorrhoids. Once the pregnancy is over, the hemorrhoids tend to improve over the next few months.
Medical history: Some patients with leukemia or bleeding diathesis will have complications from hemorrhoids. Others may be on anticoagulants, nonsteroidal antinflammatory drugs, or Plavix1. These patients will also have a tendency to bleed. If surgery is being contemplated, these drugs will have to be stopped before surgery. Patients who smoke should be counseled to stop before surgery.
Family history: Family history should include questions directed towards excluding familial col- orectal neoplastic syndromes. In certain individuals, there may be a genetic predisposition towards development of hemorrhoids. The vein walls or venous valves may be weak. These patients will have a positive family history of hemorrhoid problems.
Bowel habits: (a) Excessive straining will predispose to hemorrhoids. Some individuals habitually strain for a bowel movement. Such constant pressure causes engorgement and stretching of the vascular anal cushions. Ultimately the supporting connective tissue holding the vascular cushions is stretched and broken and the vascular cushions slide downward, presenting as hemorrhoids.
(b) Some patients with chronic constipation suffer from hemorrhoid problems. It is not clear if constipation causes hemorrhoids but constipation and straining can certainly aggravate hemorrhoids. The combination of constipation and ‘‘hemorrhoids’’ should always raise the possibility of a low-lying rectal cancer.
(c) On the other hand, patients with chronic diarrhea also develop hemorrhoids. Tenesmus from diarrhea does cause straining, and the constant irritation from loose stools will also damage the delicate hemorrhoidal veins. The combination of diarrhea and hemorrhoids should also raise the possibility of inflammatory bowel disease.
Dietary habits: The surgeon should enquire about the adequate intake of water and fiber in diet. Lack of fiber in diet is perhaps the most common predisposing factor in the development of hemorrhoids. The intake of constipating foods such as cheese and milk should be ascertained. On the other hand, diarrhea may be caused by beer, citrus fruits, lactose intolerance, and caffeine, once again aggravating the symptoms of hemorrhoids. Treatment of hemorrhoids without correcting these simple factors is doomed to fail.
Social history: It is important to enquire about social issues and lifestyle before embarking upon treatment of hemorrhoids. Treatment of hemorrhoids without correcting these factors is destined to failure: (a) Spending hours or reading books on the bathroom commode, while attempting to defecate, is an ominous sign, and any operative treatment in these patients is doomed to fail unless the habit is broken before embarking upon surgery. If the patient continues to strain for defecation after surgery, the hemorrhoids are sure to recur. (b) Some athletes, such as weight lifters and tennis players, exert themselves in extreme bursts of muscular activity which raises the intraabdominal pressure and can be associated with prolapse of internal hemorrhoids or thrombosis of external hemorrhoids. (c) Hemorrhoids may also become aggravated and irritated in patients who practice anorectal intercourse. In these patients, it is important to exclude other diseases such as abscess, fissure, or ulcers, and to evaluate the immune system before undertaking treatment. (d) Prolonged sitting and lack of activity has also been reported to predispose to hemorrhoids.
It should be made clear right at the outset that
the diagnosis of ‘‘hemorrhoids’’ should be reached only after confirming the hemorrhoids on visual and anoscopic examination and only after other sources of anorectal symptoms have been excluded. Needless to say, if a proper history is taken and a complete anorectal exam is performed, there should be no difficulty in reaching the correct diagnosis.
As with any other medical condition, diagnosis requires a proper history and a detailed physical examination. A properly taken history and physical exam will not only help make the diagnosis of hemorrhoids but also steer the surgeon towards making the correct treatment choice for a particular patient. In my opinion, the true caliber of a colorectal surgeon can be judged not by his degrees but by the care and expertise he demonstrates in the diagnosis of common anorectal ailments such as hemorrhoids.
History taking should not be considered a menial task delegated to the most junior member of the team. Instead, a thorough and systematic approach should be taken. History should be directed not only towards the symptomatology of hemorrhoids and confirming the diagnosis but also towards excluding other more sinister conditions. In addition, a proper history should assist the colorectal surgeon in making the appropriate decisions for the treatment of hemorrhoids.
The surgeon should inquire about the nature,duration, and severity of symptoms and the extent of discomfort the hemorrhoids are causing. It is also important to get a good idea about what the patient’s expectations are. Certainly a patient who has an occasional asymptomatic prolapse and is otherwise not incapacitated by the disease may not want a painful recovery from an excisional hemorrhoidectomy. Most patients with hemorrhoids have symptoms for a long period of time before they seek medical attention. Often the patients have self-diagnosed the problem and have spent months or even years trying to treat themselves with over the counter medications or ointments. Some patients, however, especially those with a nervous predisposition, present early or even after a single episode of bright red rectal bleeding. While taking the history, the proctologist should focus on the following aspects:
Age: Most patients who develop hemorrhoids are between the ages of 30 and 50. In patients who present at an unusually early age, extra care should be exercised in excluding other diagnostic possibilities such as inflammatory bowel disease, juvenile polyps, polyposis syndromes, etc. On the other hand, in older patients, the diagnosis of carcinoma should always be borne in mind.
Gender: Hemorrhoids occur in both sexes. How ever, pregnancy and childbirth are the prime causes of hemorrhoids in young females. The hormonal milieu of pregnancy, venous congestion, and increased pelvic pressure in late pregnancy and delivery all contribute to the development of hemorrhoids. Once the pregnancy is over, the hemorrhoids tend to improve over the next few months.
Medical history: Some patients with leukemia or bleeding diathesis will have complications from hemorrhoids. Others may be on anticoagulants, nonsteroidal antinflammatory drugs, or Plavix1. These patients will also have a tendency to bleed. If surgery is being contemplated, these drugs will have to be stopped before surgery. Patients who smoke should be counseled to stop before surgery.
Family history: Family history should include questions directed towards excluding familial col- orectal neoplastic syndromes. In certain individuals, there may be a genetic predisposition towards development of hemorrhoids. The vein walls or venous valves may be weak. These patients will have a positive family history of hemorrhoid problems.
Bowel habits: (a) Excessive straining will predispose to hemorrhoids. Some individuals habitually strain for a bowel movement. Such constant pressure causes engorgement and stretching of the vascular anal cushions. Ultimately the supporting connective tissue holding the vascular cushions is stretched and broken and the vascular cushions slide downward, presenting as hemorrhoids.
(b) Some patients with chronic constipation suffer from hemorrhoid problems. It is not clear if constipation causes hemorrhoids but constipation and straining can certainly aggravate hemorrhoids. The combination of constipation and ‘‘hemorrhoids’’ should always raise the possibility of a low-lying rectal cancer.
(c) On the other hand, patients with chronic diarrhea also develop hemorrhoids. Tenesmus from diarrhea does cause straining, and the constant irritation from loose stools will also damage the delicate hemorrhoidal veins. The combination of diarrhea and hemorrhoids should also raise the possibility of inflammatory bowel disease.
Dietary habits: The surgeon should enquire about the adequate intake of water and fiber in diet. Lack of fiber in diet is perhaps the most common predisposing factor in the development of hemorrhoids. The intake of constipating foods such as cheese and milk should be ascertained. On the other hand, diarrhea may be caused by beer, citrus fruits, lactose intolerance, and caffeine, once again aggravating the symptoms of hemorrhoids. Treatment of hemorrhoids without correcting these simple factors is doomed to fail.
Social history: It is important to enquire about social issues and lifestyle before embarking upon treatment of hemorrhoids. Treatment of hemorrhoids without correcting these factors is destined to failure: (a) Spending hours or reading books on the bathroom commode, while attempting to defecate, is an ominous sign, and any operative treatment in these patients is doomed to fail unless the habit is broken before embarking upon surgery. If the patient continues to strain for defecation after surgery, the hemorrhoids are sure to recur. (b) Some athletes, such as weight lifters and tennis players, exert themselves in extreme bursts of muscular activity which raises the intraabdominal pressure and can be associated with prolapse of internal hemorrhoids or thrombosis of external hemorrhoids. (c) Hemorrhoids may also become aggravated and irritated in patients who practice anorectal intercourse. In these patients, it is important to exclude other diseases such as abscess, fissure, or ulcers, and to evaluate the immune system before undertaking treatment. (d) Prolonged sitting and lack of activity has also been reported to predispose to hemorrhoids.
Azzimudin Kawajja
Surgical Treatment of Hemorrhoids
Surgical Treatment of Hemorrhoids
