Internal vs external hemorrhoids
Hemorrhoids are caused by the abnormal dilation of veins in the anus and rectum. They can be internal or external. Here are the symptoms of a hemorrhoidal crisis, the factors that promote their appearance and the existing treatments to treat them.
Hemorrhoids, what is it?
Hemorrhoids are dilated veins located in the submucosa of the anal canal that plays a physiological role in continence by contributing to the closure of the anal orifice.
Hemorrhoids are characterized by the involvement of two distinct vascular structures:
- The external hemorrhoidal plexus, whose involvement forms external hemorrhoids.
- The internal hemorrhoidal plexus, whose involvement forms internal hemorrhoids.
Causes of hemorrhoids
- Intestinal transit disorders ( constipation or diarrhea );
- In women: premenstrual phase, pregnancy, childbirth … (See also our article on hemorrhoids during pregnancy )
- Sedentary lifestyle.
- Other contributing factors have a responsibility discussed:
- Some sports: cycling, horse riding …
- Occupations exposed: drivers, pilots …
- Food: spices, alcohol …
- Some drugs: antidepressants …
- Local drugs: suppositories, enemas, irritating soap …
See also our article on What causes hemorrhoids
Signs of a hemorrhoidal crisis
- External hemorrhoids are visible below the anus.
- Internal hemorrhoids are visible only during anesthesia. They may give no symptoms, or protrude, permanently or with the push or the effort, in the anal canal.
The hemorrhoidal disease can be clinically translated by three types of signs that are already complications:
- Bleeding or rectorrhagia ;
- The perception of a ball in the anus;
- Anal pain
Hemorrhoidal hemorrhage is typically made of glowing red blood occurring at the end of the stool. Generally scanty, it stains the toilet paper or splashes the bowl. It can be the cause of anemia by its repetition. The bright red appearance of bleeding means that hemorrhoidal disease is more arterial than venous. There are indeed critical arteriovenous communications at the plexus level.
Anoscopy reveals a congestive mucosa traversed by fine red vessels. Although hemorrhoids are one of the most common causes of rectorrhagia, a colonoscopy always looks for a rectocolic lesion (cancer, etc.) that may bleed.
PERCEPTION OF AN ANAL BALL
The prolapsed hemorrhoid is the externalization of internal hemorrhoids. The patient then consults for a ball exiting through the anal canal during the stool, with the effort or permanently. Proctologic examination allows a classification of the providence according to the evolutionary stage guiding the therapeutic indications:
- Stage I: hemorrhoids protruding into the anal canal during thrusting without externalizing;
- Stage II: hemorrhoids externalizing with effort but reintegrating the anal canal spontaneously;
- Stage III: hemorrhoids externalizing with the effort but reinstating the anal canal after the pressure of the fingers;
- Stage IV: Permanent hemorrhoidal providence.
The perception of a ball in the anus may also correspond to a hemorrhoidal thrombosis but in this case, it is mainly for the anal pain that the patient consults.
See also our article on How Are Hemorrhoids Classified?
Permanent, it directs towards thrombosis or abscess; pulsatile, it searches an abscess. Provoked by the excrement, it directs towards a fissure anal.
The thrombosis is a common complication of hemorrhoids. It poses different practical problems according to whether it sits at the level of the external or internal hemorrhoidal plexuses. It is usually the formation of a hematoma rather than a right thrombosis. There is no risk of pulmonary embolism and evolution is always benign.
The external hemorrhoidal thrombosis is the most common.
Typically it begins abruptly with intense anal pain, permanent, present at night, independent of the stool, sometimes preventing the sitting position. As soon as the anal margin is inspected, the doctor notices subcutaneous, bluish, hard and painful swelling, corresponding to the clot, sometimes associated with edema. The next evolution is towards a disappearance of symptoms in a few days. Occasionally spontaneous necrosis of the sac containing the clot causes bleeding which relieves the patient. Later, she can leave as a sequela a skin fold: the marisk.
Marisci is painless skin folds at the anal margin, often labeled external hemorrhoids by patients. They must also be differentiated from the condyloma acuminata. They require no treatment unless they are associated with pruritus that they can maintain, or at the request of the patient for aesthetic reasons or for difficulties in wiping.
The internal hemorrhoidal thrombosis is most often externalized. Usually occurring on an old and procreative haemorrhoidal disease, it presents in the form of a tense and irreducible prolapse, excruciating, with a peripheral edematous zone and a reddish central zone. It can be localized or interest all the anal circumference. Sometimes internal hemorrhoidal thrombosis does not become externalized. Perceived with anal touch, it is visible during the anuscopy in the form of a small bluish clot.
The anal fissure is chronic and recurrent ulceration of the anus most often located at the posterior pole. It affects both man and woman. The pain of the crack is sharp burn type following after a free interval of 10 to 15 minutes saddle painful or not. It is sometimes a rectorrhagia punctuated by stool that worries the patient. The obligatory triggering of the pain by a saddle, the duration of the pain (one or two hours), the familiar sensation of the tight anus are very evocative. The fissure is visible on examination of the anus by slowly and gently folding the radiated folds.
There is no medical treatment of the crack. Healing products, laxatives, regularization of intestinal transit are not enough.
A local anesthetic injection (lidocaine) is the first treatment of new young crack. Secondly, the injection of sclerosing liquid at the level of the crack is often sufficient. Some prefer to practice anesthetic infiltration of the anal sphincter.
In case of failure of this treatment or old fissure, only the surgery is active on the spasm of the anal sphincter which maintains the pain: the surgeon practices a lateral sphincterotomy.
Complementary examinations and analyzes
The existence of suggestive symptoms requires a complete proctological examination in the pectoralised position (kneeling patient on the examination table) with anoscopy and rectoscopy. At the slightest doubt, the doctor completes this examination by colonoscopy to eliminate an organic lesion located higher.
Treatment of hemorrhoids
HYGIENE AND DIETARY MEASURES
They are based on useful tips:
- Regular hygiene of life avoiding all excesses;
- Remove spices and alcoholic beverages;
- Regularize intestinal transit. In cases of frequent constipation, follow a diet rich in dietary fiber, prevent stimulant laxatives and alternate osmotic laxatives, ballast or lubricant ;
- In case of itching of the anus, replace the usual toilet paper with cotton soaked in lotion based on sweet almond oil …
The veinotonic are useful during acute exacerbations although the hemorrhoidal disease is not strictly speaking a venous disease. Treatments local (ointments, creams, suppositories) are beneficial.
THE INSTRUMENTAL TREATMENT
It is performed at a distance from an inflammatory or congestive period. It is based on five techniques performed each during an anoscopy:
- Sclerosing injections consist of injecting into the submucosa, above the hemorrhoids, 1 to 2 cubic centimeters of a sclerosing product. Indications for high dosage for five days are stage I hemorrhoidal procreation and hemorrhoids. Recurrence of symptoms after treatment should suggest a different type of therapy.
- The photocoagulation using an infrared sensor. Performed in the supra-hemorrhoidal zone, it causes vascular coagulation and submucosal sclerosis. Its effectiveness is comparable to that of sclerosing injections, and it has the same indications.
- Laser destruction may be indicated.
- Elastic ligations consist of placing an elastic ring at the base of the hemorrhoidal bundle, in the supra-hemorrhoidal zone, using an apparatus allowing aspiration of the mucosa. This technique achieves a true hemorrhoidectomy (removal of hemorrhoids) at a minimum, ischemic tissue necrosis with the elimination of the hemorrhoid being done in a week or so. The indications for this treatment are stage I or II procuring hemorrhoids, that is, hemorrhoids for which sclerosing injections may be insufficient and surgery not yet indicated.
- Cryotherapy involves freezing the hemorrhoidal tissue, which then becomes necrotic using a probe traversed by nitrous oxide. Generally associated with ligatures, it seems to increase its effectiveness.
The indication of the surgical treatment can be posed from the outset in front of a permanent hemorrhoidal procidence (stage III) or irreducible internal hemorrhoidal thrombosis. Elsewhere, surgery will only be indicated after failure of well-conducted medical and instrumental treatments and in the face of disabling haemorrhoidal disease.
The treatment of thrombosis mainly uses excision, whenever possible. It is feasible in the doctor’s office under local anesthesia with xylocaine.
The semicircular or circular forms, often very oedematous, may require hemorrhoidectomy (removal of hemorrhoids) in an emergency. This intervention is well codified, and its long-term results are excellent when practiced by a trained operator. Postoperative care is essential. They aim to facilitate intestinal transit and promote healing.
See more: Thrombosed hemorrhoid home treatment