Dr. Antonio Privitera

Hemorrhoids: A Simple Definition

The term ‘hemorrhoid’ comes from the Greek and means ‘flowing blood’ and this is something not normal. Despite this, many specialized books erroneously refer to haemorrhoids as a normal part of the anatomy and this is far from the truth. Haemorrhoids are a disease of the anal cushions that consist of clusters of connective tissue, smooth muscle, and vascular structures covered by mucosa and arranged in the typically described position of 3,7,11 o’clock in the anal canal. Their function is to contribute to the anal continence at rest. Internal hemorrhoids are situated above the dentate line and are supplied by the internal hemorrhoidal plexus that is a dependence of the superior rectal vessels. External haemorrhoids are situated below the dentate line and are supplied by the external hemorrhoidal plexus that is formed by the inferior rectal vessels. These two plexuses have some communications (A-V shunts) that are usually closed in normal circumstances. In haemorrhoidal disease, these shunts sometimes open up and an internal hemorrhoid is seen to continue with external hemorrhoids without distinct separation between them. We refer to this situation as ‘internal-external hemorrhoid’. Internal hemorrhoids have visceral innervation while external hemorrhoids have somatic innervation. Dr. Antonio Privitera is a world renowned surgeon and is a hemorrhoids doctor in dubai.

Internal and External hemorrhoids

About Hemmorhoids

The prevalence of haemorrhoids in the United States of America is about 4-8%. Hemorrhoids have been reported in up to 38% of screening colonoscopies, however, only 44% are symptomatic. Age > 45 and obesity are the main risk factors.

Traditionally, internal hemorrhoids have been divided into 4 grades. Grade I hemorrhoids are seen on anoscopy as a bulge in the anal canal but no prolapse. Grade II protrude on straining but spontaneously reduce. Grade III hemorrhoids prolapsed and require manual reduction. Grade IV hemorrhoids are characterized by permanently prolapsed hemorrhoids outside the anus with the frequent presence of fibrotic changes and skin tags.a

Causes of Haemorrhoids

There are a few theories that have tried to explain the origin of hemorrhoids.  A diet poor in fibers leading to constipation and excessive straining on defecation has for long been considered the main risk factor. This could explain the higher incidence of the disease in the Western countries compared for example to the African countries. Posture in the course of defecation seems to also have an important role. In societies that have followed western habits, the sitting position during defecation produces a more acute anorectal angle with consequent greater strain on the anal canal. The straining would lead to stretching and structural changes in the anal cushions with a reduction of the venous outflow and opening of artero-venous anastomoses creating a high venous pressure system. A general laxity of tissues contributes to this mechanism. Hemorrhoids have been described in patients with Ehlers-Danlos syndrome suggesting that a collagen abnormality can be a predisposing factor. An increase in matrix metalloproteinases that regulate extracellular proteins and remodeling of tissues has been observed in hemorrhoids sufferers.

Other studies have found an association with diarrhea instead of constipation. Diarrhea itself puts a strain on the anal canal as the patient will need to empty his bowels several times a day.

Symptoms of Haemorrhoids

Internal haemorrhoids most often present with painless rectal bleeding and/or prolapse. Prolapse can produce soiling, mucous discharge, and skin irritation.  Painful internal hemorrhoids are usually the result of thrombosis, incarceration, and strangulation. Complicated external hemorrhoids are often exquisitely painful due to their somatic innervation. This may happen in the case of hematoma or thrombosis within hemorrhoids. When the clot is reabsorbed, the inflammatory reaction and healing may leave skin tags. These can become irritated or create problems with hygiene.

Symptoms of hemorrhoids are often self-limiting and respond well to conservative measures: dietary changes with an increase in fluid and fiber intake, laxatives, regular exercise, avoidance of constipation and straining, modifications of toilet habits.

External and internal hemorrhoids

Diagnosis of Hemorrhoids

The diagnosis of hemorrhoids is based on clinical history and examination. It is pivotal not to attribute rectal bleeding to hemorrhoidal disease until a full workup has been carried out. Anoscopy and rigid proctoscopy can be easily performed in the clinic. Flexible sigmoidoscopy or full colonoscopy can be carried out on a case by case basis.

Treatments for Haemorrhoids

  • Haemorrhoids treatment with fiber supplementation has been shown to decrease rectal bleeding by 50%, however, it seems to have little impact on prolapse, pain, and itching. There is no evidence to support the benefit of steroid and local anesthetic topical over-the-counter medications.
  • Phlebotonics are a class of medications that have the property to increase venous tone, stabilize the permeability of capillaries, and improve lymphatic drainage. A Cochrane review has shown that hemorrhoids treatment with phlebotonics compared to control groups improve bleeding, itching, discharge, and leakage. Mild gastrointestinal side effects are reported.

Methods of Hemorrhoids Surgery

Surgical hemorrhoids treatment includes office-based procedures that do not require anesthesia and others that are performed under local, regional, spinal, or general anesthesia. The choice of treatment depends on the Grade of hemorrhoids and the associated symptoms. Painless hemorrhoids treatment can be achieved with the new techniques that are associated with only mild discomfort.

Rubber Band Ligation

Rubber band Ligation

Rubber band ligation is the most commonly performed procedure in the outpatient department for Grade I and Grade II haemorrhoids. It can also be used for Grade III, but the risk of recurrence is high, and usually, more sessions are required. Suction devices are most often used.

The band is generally applied just above internal hemorrhoids to interrupt the blood supply and produce ischemia, sloughing, followed by ulceration and healing over a few weeks. A dull discomfort is usually felt as the band is placed above the dentate line where there is visceral innervation. Complications include severe pain (related to improper band positioning or thrombosis), urinary retention, delayed rectal bleeding, and rarely sepsis. The overall success rate is about 70%.

Stapled Hemorrhoidopexy

Stapled hemorrhoidopexy

Stapled hemorrhoidopexy is based on the concept of removing part of the lower rectal mucosa to lift the hemorrhoids and cut off the blood supply. The resulting staple line must be away from the dentate line to avoid severe postoperative pain. Usually, this is around 4 cm from the anal verge. Circumferential Grade III hemorrhoids are the ideal indication for this kind of procedure that has the advantage of reduced postoperative pain.

However, surgeons must have sufficient training on the stapling device to avoid rare but possibly described specific complications including recto-vaginal fistula, stenosis, perforation, and anal sphincter injury. Studies have shown that long-term results are better with excisional hemorrhoidectomy than hemorrhoidopexy.

Doppler-Guided Hemorrhoidal Artery Ligation

Doppler-Guided hemorrhoidal artery ligation

Doppler-guided hemorrhoidal artery ligation uses a special proctoscope with a Doppler probe that identifies and allows to tie the branches of the superior rectal artery that supply the hemorrhoids. Also, a mucopexy is performed to plicate the associated rectal mucosal prolapse.

Hemorrhoidectomy

Hemorrhoidectomy involves the surgical excision of hemorrhoids and it is associated with the best long-term results with the downside of an increased number of complications and pain. An elliptical incision is made in the skin close to the anal verge and the hemorrhoid column is dissected off the internal sphincter and its pedicle divided. This is a critical step of the procedure as an injury to the internal sphincter may lead to incontinence. Also, it is mandatory to preserve bridges of intact mucosa to prevent anal stenosis. The wound defect can be left open to heal (Milligan-Morgan technique) or closed with sutures (Ferguson technique). Postoperative pain can be severe in the first few days and this is the reason why numerous mini-invasive techniques have been developed.

Laser Hemorrhoid Treatment

Laser hemorrhoid treatment is a technique that produces shrinkage of the hemorrhoids through the insertion of a laser probe into the hemorrhoid tissue. Attention should be taken not to direct the probe towards the internal anal sphincter and to apply ice after each application to reduce heat damage. A mucopexy is also performed. Pain is less than traditional hemorrhoidectomy.

Sclerotherapy

Sclerotherapy is an outpatient procedure to treat mainly Grade I and II hemorrhoids.  A sclerosant agent (5% phenol, ethanolamine, hypertonic saline) is injected producing fibrosis and fixing the tissue to the anal canal. Studies have shown that sclerotherapy has a lower success rate than rubber band ligation with a similar number of complications.

Infrared Coagulation

Infrared coagulation is an alternative outpatient modality that involves the application of an infrared coagulator to the hemorrhoids until blanching is seen. This will eventually cause scarring and tissue retraction.

Emergency Hemorrhoids Surgery

Emergency surgery for internal hemorrhoids should only be performed in case of strangulation or inability to reduce incarcerated hemorrhoids caused by prolapse with anal sphincter spasm. Most of the time emergency reduction can be obtained after the application of sugar or salt to reduce edema. Thrombosed external hemorrhoids are usually severely painful in the first 48-72 hours. Subsequently, the pain subsides as the hematoma is reabsorbed. Conservative measures with fiber supplements, laxatives, and local anesthetic are usually adopted. Unroofing of external hemorrhoids and evacuation of the clot or full excision is indicated in cases of severe pain non-responding to analgesia and case of recurrent symptoms.

Haemorrhoids Doctor in Dubai

Most surgeons and some physicians commonly perform hemorrhoids treatment in Dubai. However, patients must be aware that the best results of hemorrhoids treatment in Dubai are achieved by colorectal surgeons who have a full understanding of the anatomy and they are skilled with the various techniques and able to tailor treatment to each individual. Problems that may arise from improper treatment include fecal incontinence and severe long-lasting pain that severely impair the quality of life. People would generally search on internet search engines for a “Hemorrhoids Doctor in Dubai” and be confused by the many clinics and hospitals offering a vast array of options. A hemorrhoids treatment doctor in Dubai should be a colorectal surgeon with reputable fellowship training, a member of colorectal societies, and with a dedicated history of practice in the field. A hemorrhoids treatment doctor in Dubai should well know when not to operate and how to best resolve the patient’s symptoms.  In the absence of prolapse, a hemorrhoids doctor should not perform a stapled hemorrhoidopexy. Any hemorrhoids treatment doctor in Dubai should know that there is no point in treating surgically thrombosed external hemorrhoids after 72 hours. The hemorrhoids treatment doctor in Dubai should consider a formal hemorrhoidectomy for Grade IV hemorrhoids, especially when fibrotic changes and multiple skin tags are present.

Looking for a Hemorrhoids Doctor in Dubai?

A proctology service not only for hemorrhoids treatment but also for many other diseases is currently operating in NMC Royal Hospital Dubai Investment Park- DIP. Currently, Dr. Antonio Privitera is offering a free consultation for haemorrhoids treatment in the same hospital in Dubai.

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