HEMORRHOIDS
What are hemorrhoids?
Hemorrhoids are swollen veins located in the lower rectum or anus.
Normal Anatomy:
Anatomy of Hemorrhoids:
There are two types of hemorrhoids based on location. Internal and external hemorrhoids:
Internal Hemorrhoids: Occur inside the lower rectum and often can’t be seen or felt. As this form is typically painless, the only symptoms you may notice are small amounts of bright red blood (on the toilet paper or inside the toilet bowl) or a feeling of fullness following a bowel movement. Occasionally, internal hemorrhoids can push through the anal opening. This is known as a prolapsed, or protruding, hemorrhoid. Sometimes these swollen veins temporarily prolapse; in other cases, they become permanent. This prolapse can cause a deposit of mucus on the skin, which can often cause a rash or itching. These changes can also cause the formation of excess skin (tags). If the hemorrhoid remains outside the anus, it can cause pain as well.
Internal Hemorrhoids are classified as:
Grade 1: There are small internal hemorrhoids but no prolapse from the anal canal. These produce painless bleeding.
Grade 2: These bleed but also prolapse from the anal canal when the patient strains. They retract after the bowel movement and often the patient does not even know they are prolapsing.
Grade 3: These are easily identified because they prolapse with a bowel movement and can be pushed back in. Grade 3 hemorrhoids may be associated with bleeding and perhaps with an aching pain.
Grade 4: These hemorrhoids remain prolapsed externally all the time and won’t stay reduced. There is often a mucoid discharge from the hemorrhoids along with bleeding.
External Hemorrhoids: Occur as bulges or lumps around the anus. Because of the sensitive nerve fibers in this area, these enlarged veins are often painful, especially when sitting. They also may bleed and itch. Should blood pool in an external hemorrhoid a blood clot referred to as a thrombosed hemorrhoid may develop and cause severe pain. This is often associated with anal spasm. The less common of the two forms, external hemorrhoids are often incorrectly self-diagnosed because many people mistake internal hemorrhoids, or the skin tags they can produce, for external hemorrhoids.
What causes hemorrhoids?
Hemorrhoids result from an increase in pressure in the veins of the rectum. This may be caused by constipation, pregnancy, childbirth, obesity, heavy lifting, long periods of sitting, or diarrhea. In Western countries, constipation is associated with diets low in fiber and high in fat.
What symptoms are caused by hemorrhoids?
Depending on the location, symptoms may include pain, inflammation, itching, and a feeling of fullness following a bowel movement. Additionally, there may be bright red blood covering the stool, on the toilet tissue or in the toilet bowl. Occasionally the blood can be felt to drip from the rectum into the toilet bowl water.
Who gets hemorrhoids?
Hemorrhoids affect both men and women. The incidence of hemorrhoids increases after age 30, and by age 50, about half of the population will have experienced the condition.
Natural history of hemorrhoids:
Hemorrhoids get larger with time and may bleed or itch at the beginning but later come out transiently or even stay out all the time. Tags can form on the outside and sometimes the hemorrhoids can thrombose and become very painful. When there are large tags it may be difficult to keep the area clean and there may be a discharge and itch or irritation. After the age of 50 years 50% of people will have hemorrhoids but only 1% will need treatment each year. 97% of those treated are with banding.
What treatments are available for hemorrhoids?
An occasional episode of symptoms from hemorrhoids can be treated using local measures, suppositories, diet, fiber and adequate oral liquids. However, further treatment is needed in some cases. Banding of hemorrhoids with the CRH O’Reagan banding device is an essentially painless method of treatment designed to get rid of hemorrhoids.
Local measures:
The best treatment is prevention by taking enough dietary fiber and liquids by mouth (see below for further discussion). The addition of a topical cream (no difference between most of the emollient creams, so go cheap) is usually sufficient. The use of a steroid cream or analgesic ointment should generally not be used for longer than a week. Suppositories can be helpful.
An important change that will help is not spending longer than 2 minutes on the toilet to have a bowel movement, and going back a few hours later if you cannot have a bowel movement then. Regular exercise helps to promote normal bowel habits.
If these measure do not work, you will likely be sent to a specialist who will first of all make sure that hemorrhoids are the only problem. If there is a family history of cancer, or if there is weight loss or blood mixed in with the stool or a lot of pain, other causes such as inflammatory bowel disease, fissure or even bowel cancer will need to be ruled out.
Diet
For a healthy diet you should have:
- Correct quantity and balance between food groups (see the new Harvard food pyramid online: www.hsph.harvard.edu/nutritionsource)
- Adequate water intake
- Enough soluble and insoluble fiber for a total of more than 30 grams daily. As above, you may need supplements to achieve this amount.
- Desirable fats
- Lean Protein
- Complex carbohydrates
Adequate water intake: We recommend 7-8 (12oz) glasses of water or other clear liquids per day.
Enough Soluble Fiber: For colorectal health a minimum of 25 grams of soluble and insoluble fiber a day is required.
Lack of fiber is implicated in constipation, high cholesterol, higher risk of colo-rectal cancer, maturity onset diabetes and obesity among other diseases.
In the morning you should take 2 -4 tablespoons of oat or wheat bran or flax or Metamucil or Benefiber. These can be added to your cereal in the morning or mixed in with yogurt or put in soup. You must take in 7 to 8 (12 ounce) glasses of water daily for this to work properly.
There can be problems with the regimen if you have kidney problems or are on water pills (diuretics) and your doctor will change this plan for you.
Some may have an allergy to wheat, for this reason we prefer oat bran rather than wheat bran as a soluble fiber supplement.
Fiber Recommendations
The lack of dietary fiber and fluids is a contributing factor to the development of hemorrhoids and anal fissures. We recommend consuming 25-35 grams of fiber and drinking 7 glasses of fluids per day. Fiber can improve the form, bulk, and size of the stool. The addition of 10-20 grams of fiber per day will improve bowel habits and colon health. This may be done by modifying your
diet or adding fiber supplements. Fiber will also help decrease your cholesterol, improve your glucose control, and may reduce your risk of diverticulosis, colon cancer, heart disease, and stroke.
Water soluble fiber is preferred and is found in oats, beans, cabbage, squash, carrots, apples, citrus fruits, prunes, strawberries, pears, etc. Soluble fiber forms a viscous gel that increases the amount of water that stays in the colon and coats the intestinal walls which decreases cholesterol absorption and serves as a substrate for fermentation by colonic bacteria. Insoluble fiber passes through the digestive system largely intact. They improve bowel consistency by increasing the water in the stool. Cellulose and lignin are forms of insoluble fibers that increase stool bulk by increasing the microbial mass. The cells are 80% water and this is the main way fruits and vegetables increase the stool size and make them softer. Cellulose is found in whole wheat, bran, cabbage, peas, green beans, wax beans, broccoli, cucumber skins, peppers, apples, and carrots. Lignin is found in cereals, bran, strawberries, eggplant, pears, green beans, and radishes. Brussel sprouts and beet root contain hemicellulose that also increases water holding capacity. They improve stool consistency by increasing the amount of water that stays in the colon and by increasing viscosity. These viscous solutions decrease the rate of gastric emptying, which leads to a slowing of digestion and increased absorption of nutrients.
Increase the amount of fresh fruit and leafy vegetables in your diet. Oatmeal, oat bran, nuts, dried peas, beans, lentils, apples, pears, strawberries, blueberries should be added to your diet for soluble fiber. Use more whole fiber grains, breads, and cereals. It may take up to six weeks to see a benefit. The amount and type of fiber that benefits you the most is variable and must be determined by trial and error. Many sources contain both soluble and insoluble fiber.
Fiber is a polysaccharide, which are carbohydrates found in plants that can not be broken down all the way to simple sugars and thus pass through the intestine partially undigested. The fiber is broken down into short-chain fatty acids, hydrogen, methane, and carbon dioxide. A particular food item will be a combination of nutrients and fiber that will determine how fast it is digested and how much will be quickly turned into simple sugar versus how much will be undigested and serve to increase the stool bulk. The various soluble and insoluble fibers have more specific names. There’s bran, cellulose, gum, hemicellulose, lignin, mucilage and pectin. Each specific fiber serves a specific function as a soluble and/or insoluble fiber type:
- Bran, gums and mucilages—help to regulate blood glucose, aid in lowering cholesterol and help in the removal of toxins.
- Cellulose—an indigestible carbohydrate that is found in the outer layer of fruits and vegetables, so eat the peel and savor the stems. Cellulose absorbs toxins in the intestine and is especially helpful in preventing constipation, hemorrhoids, varicose veins and colitis.
- Hemicellulose—an indigestible complex carbohydrate that also absorbs water. This fiber type is good for promoting weight loss, relieving constipation, preventing colon cancer and controlling carcinogens in the intestinal tract.
- Lignin—an insoluble, woody substance that comes from the stems and seeds of fruits and vegetables and in the bran layer of grains. Lignins help lower cholesterol and help prevent the formation of gallstones by binding with bile acids and removing cholesterol before stones can form. It’s helpful in preventing and managing diabetes and colon cancer and perhaps other cancers as well.
- Pectin—Soluble fibers that form highly viscous solutions that decrease the rate of gastric emptying, slows the intestinal absorption of food, increases absorption of nutrients along a greater length of the small intestine, reducing blood glucose and consequent insulin spikes.
Warnings
We recommend rotating the food and fiber types. Avoid foods to which you have food allergies, intolerances or sensitivities. Gradually increase the fiber in your diet until your bowel movements are optimum for you (consult your physician for information and guidance). A temporary increase in intestinal gas is to be expected. Fennel seed may help reduce flatulence. Diabetics should not change their diet without consulting their physicians as fiber may affect your blood sugar. Excessive fiber via supplements may decrease the absorption of iron, zinc and calcium. Finally, be patient as it may take 6 weeks to see the ultimate benefit of adding fiber to your diet. For persistent constipation or change in the caliber of your stool see your doctor.
Supplements
You can add 10 grams of fiber with two tablespoons of whole oat bran or wheat bran, psyllium (a seed native to Iran and India), Metamucil (http://www.metamucil.com/specific_conditions/hemorrhoids.shtml ),
Citrucel (methylcellulose) or Benefiber www.benefiber.com
Check out Fibersure which is made from inulin and comes from chicory root. 1 tsp equals 5 grams of fiber. It is very easy to use, can be mixed with any food, has no taste, and is for sale in the grocery stores. http://www.fibersure.com/index_flash.shtml
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