| Chronic Constipation and the Risk of Hemorrhoids
12/11/2009 |
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Conventional wisdom tells us that every time we strain to have a bowel movement, we further the possibility of developing hemorrhoids. Hemorrhoids result when vasculature in the anal canal is put under increased pressure and becomes engorged. These vessels may be internal or external, thrombosed or not thrombosed. Features include bleeding, itching, prolapse, and pain. Bright red blood from the rectum is often an indication of hemorrhoids, but anal fissure, fistula, abscess, and cancer can also be in the differential. Those who have previously experienced hemorrhoids know that the best treatment is to avoid a recurrence.
There is nothing worse for development of hemorrhoids than a chronic case of constipation. Drugs and specific behaviors (straining or delaying defecation) may also increase intraluminal pressure. Pregnancy and delivery also contribute to hemorrhoids in women. The best way to prevent hemorrhoids is with a bulky stool, regular bowel movements, and limiting stimulants on the bowel wall muscularis (e.g., caffeine). There is a significant benefit from fiber supplementation to reduce hemorrhoidal bleeding. (1,2)
The benefits of fiber for irritation and pruritus are less well established than for bleeding. (3) However, fiber is generally recommended even in these situations as it reduces the chemical irritation from leakage and fecal soiling. In order to prevent constipation, all elements of treatment can be brought to bear. For patients where fiber does not relieve constipation or when it causes intolerable side effects, laxatives have a role. (4)
Over-the-counter preparations for constipation include bulk-forming laxatives, stool softeners, lubricant laxatives, stimulant laxatives, saline laxatives, enemas and suppositories. Clinicians should also be mindful of what evidence exists for the elderly patient population in treating their condition. The last definitive word from the American College of Gastroenterology was published in 2005 (5), but at least one newer agent, lubiprostone, has shown effectiveness in a population over age 65. Lubiprostone is a bicyclic fatty acid (prostaglandin E1 derivative) that acts by specifically activating ClC-2 chloride channels on the apical aspect of gastrointestinal epithelial cells, producing a chloride-rich fluid secretion. These secretions soften the stool, increase motility, and promote spontaneous bowel movements. The task force cited insufficient data to make recommendations for all other treatments, including combination laxatives.
Thrombosed hemorrhoids often come to our attention as the process starts to resolve. The pain of the thrombosis comes from the intraluminal pressure exerted by the clot and the necrosis of the vascular wall. Early on they can be excised under local anesthesia in the outpatient setting. Conservative therapy including sitz baths tends to provide relief as the thrombosis organizes and resolves. Because diarrhea exacerbates hemorrhoidal symptoms, controlling it with fiber, antimotility agents and specific treatments of any underlying cause will likely be of benefit.
Very few patients require an aggressive approach and most patients will have relief with conservative or minimally invasive therapies. Nonoperative treatments include injection sclerotherapy, diathermy coagulation, bipolar coagulation, infrared coagulation and rubber band ligation. Cryotherapy is no longer recommended. Hemorrhoidectomy can provide great benefit in selected cases, though it is associated with significantly more pain and complications than nonoperative techniques. There is also the hazard of rectal stricture or incontinence with surgery. Only about 5% to 10% of patients, usually those with third-or forth-degree hemorrhoids, need surgical hemorrhoidectomy. (6)
Editorial by:
Eric G. Tangalos, MD, FACP, AGSF, CMD
Professor of Medicine and Chair (Emeritus)
Primary Care Internal Medicine
Mayo Clinic College of Medicine
Medical Director
Samaritan Bethany Heights Skilled Nursing Center
Rochester, MN
References:
1) Madoff RD, Fleshman JW. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology. 2004;126:1463-1473.
2) Banov L Jr, Knoepp LF Jr, Erdman LH, Alia RT. Management of hemorrhoidal disease. Journal of the South Carolina Medical Association. 1985;81(7):398-401.
3) Perez-Miranda M, Gomez-Cedenilla A, Leon-Columbo T, Pajares J, Mate-Jiminez J. Effect of fiber supplements on internal bleeding hemorrhoids. Hepato-Gastroenterology. 1996; 43(12):1504-1507.
4) Alonso-Coello P, Guyatt G, Heels-Ansdell D, Johanson JF, Lopez-Yarto M, Mills E, Zhou Q. Laxatives for the treatment of hemorrhoids. Cochrane Database Systematic Reviews. (4):CD004649;2005.
5) Brandt LJ, Prather CM, Quigley EM, Schiller LR, Schoenfeld P, Talley NJ. Systematic review on the management of chronic constipation in North America. Am J Gastroenterol. 2005;100(suppl 1):S5-S21.
6) Bleday R, Pena JP, Rothenberger DA, Goldberg SM, Blus JG. Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum. 1992;35:477-481.
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