Why are hemorrhoids called "hemorrhoids" instead of "asteroids"?  - Internet joke
Get Rid of Hemorrhoids

performed a little experiment at a drugstore recently, to test what could be called the body-part taboo hypothesis. I wanted to see which parts of the body have the least social acceptance. I suspected that the most taboo part was not what we might expect and that, consequently, we give it inadequate attention.

  Figure 1. Normal anorectal canal
Please realize that my test was not double-blind or placebo-controlled and was subject to the bias of the researcher - myself. What I did was ask four clerks (two of each sex) to help me locate four different products in the aisles: sanitary  napkins, toenail fungus creme, condoms, and hemorrhoid creme. I queried an additional sixteen clerks (eight women and eight men), but for only one product each. Can you guess which query produced the most discomfort, roughly measured by lost eye contact, voice hesitancy, uptightness, and other signs of ill ease?

Sanitary napkins were the least objectionable, even for the men, both of whom knew exactly where to find them. Next, but still easy to find, were the fungus creme and - would you believe it? - the condoms. Even the women (my test was done in California) were very matter-of-fact about those. But when it came to the hemorrhoid creme, the ground became shaky. It seemed as if everyone winced and felt uncomfortable. I got the feeling that the sooner the conversation ended, the better. Judging from this very small sample, the results seem to indicate that the anal and rectal region of the body are not accorded the same respectful attention as the genitals or toes (see Figure 1).

Figure 2. Anorectal canal with hemorrhoids
HEMORRHOIDS MAY BE THE FIRST SIGN OF UNHEALTHY VEINS
Hemorrhoids are enlarged, bulging veins in and around the anus (see Figure 2). As with varicose veins of the legs, which are superficial (near the surface of the skin) and are thus often regarded as having no real connection with any other part or system of the body, so it is with hemorrhoids. They appear at first as an occupational hazard, e.g., people who stand on their feet all day are more likely to have them earlier than others. But indeed they are age-related, and slightly sex-specific. Women are more prone to hemorrhoids, perhaps due to pregnancy, but both sexes become increasingly vulnerable with age. Hemorrhoids are related to the wear and tear that comes with age and should be a clue that they represent systemic changes in the entire venous system.

PROBLEMS ASSOCIATED WITH HEMORRHOIDS
Are hemorrhoids any different from varicose veins in terms of their reflection of declining venous health? If so, is there an iceberg below the surface? If unattended or not resolved, what are the possible complications? Procrastination in seeking appropriate management is characteristic of both patient and physician alike,1 until the moment when urgency becomes emergency.

Thrombosed Hemorrhoids Everybody gets hemorrhoids, and they're controllable by lifestyle, including exercise and diet - or so goes the litany. As we saw last month  (Mending Varicose Veins - October 1999), this is not likely. Instead, just about anyone who has varicose veins is also likely to experience more serious, sometimes even life-threatening, problems with venous insufficiency. For example, the frequency of venous thrombosis (blood clots) appears to be increased in patients with varicose disease.2

If unattended - many people do not initially give them the attention they deserve - hemorrhoids may become thrombosed when blood clots form inside the hemorrhoid itself, causing acute pain and usually requiring immediate medical attention. According to Dr. Stephen Gorfine, associate clinical professor of surgery at Mount Sinai School of Medicine in New York City, many patients with thrombosed hemorrhoids opt for surgery even though the blood clots typically dissolve within three weeks, and severe pain diminishes within three to seven days.3 The condition is so painful, he says, that patients prefer not to wait. "People who have these things will do anything to relieve the pain," says Gorfine.

Anorectal Incontinence Conventional medical explanations for the incapacity to control the bowels include anal, rectal, or neurologic lesions (abnormal or damaged areas) as the main causes. When hemorrhoids are removed surgically, important tissue is frequently lost that may result in incontinence.4 This tissue, known as the corpus cavernosum recti, governs continence and is often he site of hemorrhoids. Although few fatalities have ever been reported in the literature following surgical removal of hemorrhoids, they have occurred for other hemorrhoid treatments, including "banding" procedures and injection therapy.

Research at the Johns Hopkins Medical School's John Radcliffe Hospital attributes fecal incontinence in women almost exclusively to botched surgery of the anal sphincter or the nerves of the anal musculature.5 In men, hemorrhoids are less commonly the result of sphincter damage, almost all of which is caused by anal surgery.

Diarrhea Although studies connecting anorectal health problems to larger systemic problems have not yet been done, there are early indications that such connections exist, vis-a-vis not only the venous system, but also the gastrointestinal tract and the immune system. One epidemiological study involving 8.8 million Medicare patients hospitalized in the United States during 1987 suggests that diarrhea may represent a risk factor for hemorrhoidal disease.6 Among the diarrheal disorders implicated were ulcerative colitis, noninfectious gastroenteritis (inflammation of the gastrointestinal tract), and functional diarrhea (diarrhea lasting at least 12 consecutive weeks during the last 12 months).  Hemorrhoidal disease was likewise closely associated with benign and malignant anorectal tumors.

Colorectal Cancer Although hemorrhoids are not directly connected to colorectal cancer, their presence may mask colonic lesions (such as polyps or cancer), especially when the hemorrhoids bleed. One study involving 103 outpatients found such a masking effect, in which clinicians could not distinguish between hemorrhoidal bleeding and bleeding from internal lesions.7 In addition to tumors and hemorrhoids, rectal bleeding may also be caused by polyps, ulcerative colitis, amebic colitis, neoplasm, diverticulosis, anal fissure, Crohn's disease, and arteriovenous malformations.8

Hemorrhoids are related to the wear and tear that comes with age and should be a clue that they represent systemic changes in the entire venous system.

DIET AND HEMORRHOIDS
In a recent study to determine the role that certain foods play in the origins of hemorrhoids or their acute exacerbation, the diets of 50 volunteers with no anorectal abnormality were compared with those of 50 volunteers with hemorrhoid symptoms.9 Overall caloric intake, including protein, carbohydrate, and fiber, was similar in the two groups, as was the use of salt, coffee, and tea. On the other hand, the hemorrhoid group consumed more fat, alcohol, pepper, and pimento, and they drank less water, smoked more, and were more often constipated.

HEMORRHOIDS ARE VARICOSE VEINS
Hemorrhoids, traditionally known as piles, are but a special case of varicose veins, affecting the anus and the lower rectum, just as varicose veins affect the legs. Generally, it is excessive pressure on the veins in the anorectal area, causing them to stretch and swell, that leads to hemorrhoids, which are perhaps the most common problem of the lower digestive tract. When the swollen veins are scratched or broken by straining or rubbing, they begin to bleed. 

There are two varieties of hemorrhoids: internal and external. About an inch into the anal canal is a set of veins that, when swollen, become internal hemorrhoids. When stressed, these may bleed significantly, but they are painless. Under the skin surrounding the anus are the veins that can become external hemorrhoids. These can easily be seen or felt, and they can be very painful. It is possible for the internal veins to stretch so much that they protrude from the anus and become "external" too. These are known as prolapsed hemorrhoids, and they can become irritated and painful. The overwhelming majority of hemorrhoids are internal without prolapse. 

FACTORS THAT CONTRIBUTE TO HEMORRHOIDS

  • Straining from constipation
  • Delaying the urge to defecate
  • Sitting too long on the toilet
  • Straining on the toilet
  • Stress
  • Standing or sitting for long periods
  • Obesity
  • Alcohol
  • Excessive coughing or sneezing
  • Pregnancy and the strain of childbirth
  • Heavy lifting
WHAT ARE THE MOST COMMON SYMPTOMS?
  • Itching, mild burning, and bleeding from the anus
  • Painful lumps, varying in size from a pea to a walnut, around the anus
  • Painful bowel movements (particularly with inflamed prolapsed hemorrhoids)

HOW ARE THEY TREATED?
Nutritional changes are a good idea, including a high-fiber diet to prevent constipation. Good sources of fiber include whole fresh fruit; raw or cooked vegetables, especially asparagus, cabbage, carrots, corn, and broccoli; and whole-grain cereals with bran. It is also prudent to add adequate fluids to your daily regimen to make looser stools and increase the gastrointestinal-tract transit time. Daily intake, including plenty of water, should be at least six to eight 8-ounce glasses of fluid (alcohol doesn't count and should be restricted). Horse chestnut extract, along with troxerutin, diosmin, and hesperidin, can help restore venous health and prevent the future occurrence of hemorrhoids.

Relief from the discomfort of hemorrhoids is possible by sitting in warm water (called a sitz bath) two or three times a day for 15 minutes. Alternatively, you might try putting cold packs on the anus to relieve pain. When you rest, raising your bottom can be helpful.

FLAVONOIDS HELP HEMORRHOIDS
A variety of rare flavonoids, including troxerutin,10 diosmin, and hesperidin,11 have been shown to produce marked relief from hemorrhoids in short order. Flavonoids are present in a variety of foods, but not in sufficient amounts to make a difference when it comes to maintaining venous health. The approach of using phytonutrients (chemicals derived from plants) is quite different from the conventional approach, which is heavily weighted toward surgery. The idea behind the use of flavonoids and other plant-derived substances, such as horse chestnut extract, is to restore health to the entire venous system and increase resistance to stress and other factors that can result in inflammation, dysfunction, edema, thrombosis, and the promotion of disease.

Reviewing some of the highlights of last month's varicose vein article and their application to hemorrhoids, in one placebo-controlled study, 97 women with advanced hemorrhoids were given 1000 mg/day of troxerutin.12 After two and four weeks of treatment, the bleeding, inflammation, and enlargement of their hemorrhoids improved dramatically versus the placebo group, without side effects.

In another study lasting just one week, 1350 mg of diosmin and 150 mg of hesperidin given for four days, and then 900 mg of diosmin and 100 mg of hesperidin given for three days, produced marked relief from hemorrhoidal attacks.13 Of 100 subjects, 50 received the flavonoids and 50 received placebo. Anal discomfort, pain, and discharge diminished to a greater extent in the flavonoid group, as did inflammation, congestion, edema, and prolapse. Their use of analgesics and topical medications dropped.

In yet another study, involving 120 individuals (54 men, 66 women) suffering from acute and chronic recurrent hemorrhoids, the subjects were group-divided and given either placebo or 900 mg of diosmin and 100 mg of hesperidin.12 After two months, there were only about half as many attacks in the flavonoid group, and they lasted about half as long. Also, the flavonoid group reported a reduction in symptoms to practically the zero point: they rated the severity of their hemorrhoidal symptoms at 1.1 on a scale ranging from 1 to 15 (highest).

HORSE CHESTNUT CAN HELP TOO
Horse chestnut extract has been used successfully in Europe for varicose veins and venous insufficiency.13 Since hemorrhoids are varicose veins too, albeit of a different part of the body, it seems likely that horse chestnut can also be helpful in the nether region, because the same factors that weaken any part of the venous system may very well be operative throughout.

THE END OF HEMORRHOIDS
Is it true that most people give insufficient attention to their derrieres until it's too late? If you've never experienced hemorrhoidal discomfort, be aware that venous problems are problems of aging. The veins in your anus are just as important as the ones in your legs. They need to last. However remote they may seem to be, remember that what you do to prevent or alleviate hemorrhoids may have longer-range consequences and serve your overall health from stern to bow. It pays off at the end to use scientifically proven flavonoids and phytonutrients to put an end to hemorrhoids.

To understand the mechanism of action of horse chestnut and flavonoids and why they are also good for your entire venous system, helping to prevent varicose veins and perhaps even deep-vein thrombosis, see Mending Varicose Veins - October 1999.

References

  1. Trilling JS, Robbins A, Meltzer D, Steinbardt S. Hemorrhoids: associated pathologic conditions in a family practice population. J Am Board Fam Pract 1991 Nov-Dec;4(6):389-94.
  2. Guex JJ. Thrombotic complications of varicose veins. A literature review of the role of superficial venous thrombosis. Dermatol Surg 1996 Apr;22(4):378-82.
  3. Nitro for hemorrhoids. Reuters Health Service. June 24, 1997; http://www.reutershealth.com/frame_archive.html
  4. Stelzner F. Hemorrhoidectomy - a simple operation? Incontinence, stenosis, fistula, infection and fatalities. Chirurg 1992 Apr;63(4):316-26.
  5. Chen H, Humphreys MS, Kettlewell MG, Bulkley GB, Mortensen N, George BD. Anal ultrasound predicts the response to nonoperative treatment of fecal incontinence in men. Ann Surg 1999 May;229(5):739-43; discussion 743-4.
  6. Johanson JF. Association of hemorrhoidal disease with diarrheal disorders: potential pathogenic relationship? Dis Colon Rectum 1997 Feb;40(2):215-9; discussion 219-21.
  7. Segal WN, Greenberg PD, Rockey DC, Cello JP, McQuaid KR. The outpatient evaluation of hematochezia. Am J Gastroenterol 1998 Feb;93(2):179-82.
  8. Shennak MM, Tarawneh MM. Pattern of colonic disease in lower gastrointestinal bleeding in Jordanian patients: a prospective colonoscopic study. Dis Colon Rectum 1997 Feb;40(2):208-14.
  9. Sielezneff I, Antoine K, Lecuyer J, Saisse J, Thirion X, Sarles JC, Sastre B. Is there a correlation between dietary habits and hemorrhoidal disease? Presse Med 1998 Mar 21;27(11):513-7.
  10. Wijayanegara H, Mose JC, Achmad L, Sobarna R, Permadi W. A clinical trial of hydroxyethylrutosides in the treatment of haemorrhoids of pregnancy. J Int Med Res 1992 Feb;20(1):54-60.
  11. Cospite M. Double-blind, placebo-controlled evaluation of clinical activity and safety of Daflon 500 mg in the treatment of acute hemorrhoids. Angiology 1994 Jun;45(6 Pt 2):566-73.
  12. Godeberge P. Daflon 500 mg in the treatment of hemorrhoidal disease: a demonstrated efficacy in comparison with placebo. Angiology 1994 Jun;45(6 Pt 2):574-8.
  13. Pittler MH, Ernst E. Horse-chestnut seed extract for chronic venous insufficiency. A criteria-based systematic review. Arch Dermatol 1998 Nov;134(11):1356-60.

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