Haemorrhoids - the golden vein 

Who else but Hyppocrates used the word "hemorrhoid" consisting of the ancient Greek words "hema," blood, and "rhoos," to flow, forming the meaning of flowing blood. The foregoing already tells us that this disease was known and described very long ago, and it logically follows that it was already quite common at that time. However, the exact incidence and prevalence of the disease is still not completely clear, mainly related to frequent self-treatment, shyness to see a specialist, asymptomatic course, but also false positive findings of a physiological condition and not the disease.

What are hemorrhoids

As Mr Hippocrates himself has already hinted, it is a disease in which blood flows from something - that is, it is bleeding from the blood vessels. Anatomically, these blood vessels are located at the end of the rectum under the mucous membrane and are referred to as the internal haemorrhoidal plexus. A little lower down under the skin of the end of the anal canal are the external haemorrhoidal plexuses and we refer to them as external haemorrhoids. Even the anatomical position has a huge influence on the manifestations of the disease and the treatment itself.

Haemorrhoids on the rectum

Hemorrhoidal plexuses, i.e. vascular plexuses, are also physiologically present in that location without causing any inconvenience and even have their role. I recently saw a video on Facebook where an unnamed doctor, supposedly a specialist, speaks to patients via a social networking site and guarantees to 'remove haemorrhoids completely'. Believe me, you definitely wouldn't want that! I'll paraphrase a scene from a movie, I think it's called Pulp Fiction: "your ass would subsequently experience the Middle Ages" if the hemorrhoids were removed completely.

But let's go back from the film to the pathophysiology and pathology. So we know that hemorrhoids are blood vessels, they are filled with blood that flows in them and they are also a physiological part of the anal canal.

How hemorrhoids arise - the golden vein

Internal hemorrhoids

Let's imagine very simplistically that internal hemorrhoids are balloons of varying sizes filled with blood under the mucous membrane, as opposed to external hemorrhoids, which are under the skin. Blood is fed and drained into both. Under pathological circumstances, these balloons gradually begin to enlarge, the diameter of the blood vessels widens and the wall of the balloon automatically becomes thinner. The enlarged, filled balloons are at the end of the tunnel through which the "mole" occasionally walks. The mole comes out of the tunnel spilling a pile! But what can happen? At first the balloons are slightly filled with their weight but still stay in place, but occasionally one may burst and stain the mole, or the mole pile, or just the paper, so you will bleed.

External hemorrhoids

But what happens if the balloons keep getting bigger? Well, they burst more often, you can observe more blood and besides that they are heavier, the mole has a harder time avoiding them and is often very full and starts dragging them out of the tunnel with him. In worse cases, advanced stages, they stay sticking out of the tunnel, sometimes for a while, sometimes we have to push them in, and sometimes they are so big and heavy that they can't go back in even after being pushed in.

Hemorrhoids, Golden vein - symptoms

How hemorrhoids manifest themselves

The mole-balloon theory from the previous paragraph can also be applied to the staging of the disease.

Types of hemorrhoids

• 1st degree of hemorrhoidsA: When hemorrhoids just pop and bleed, you have Stage 1 hemorrhoids.
• 2nd degree of hemorrhoidsA: When hemorrhoids come out with the mole but then hide, you have Stage 2 hemorrhoids.
• 3rd degree of hemorrhoidsA: If you have to push the hemorrhoids to keep them out of your garden, you have Stage 3 hemorrhoids.
• 4th degree of hemorrhoids: If you can't even push them anymore and you have a "pretty flower" around the tunnel in addition to the mole hill, you have 4th stage of hemorrhoids.

The clinical manifestations of haemorrhoids follow beautifully from the above. Since the balloons are under the mucosa of the lower part of the ileum, which is not innervated the most common manifestation is painless bleeding, i.e. bleeding haemorrhoids and the second manifestation is coming out of the tunnel with a mole, which we proctologists professionally call prolapse. The above two manifestations are the primary symptoms of hemorrhoidal disease.

Painful hemorrhoids and mucus

When we dirty our "garden" in the advanced stages of haemorrhoidal disease, there is also mucus spotting and associated irritation of the surrounding skin with itching. The above is often accompanied with discomfort of various nature. It is certainly not pleasant when something bursts, pricks, cuts slightly or sticks out... Uncomplicated internal haemorrhoids do not hurt. Complicated internal hemorrhoids hurt extremely, they are painful hemorrhoids. /Pulp fiction/.

External haemorrhoids, these bother most of your patients, but only occasionally us proctologists.This is a stumbling block, patients often think that what they have around the anal canal is the problem, but the problem is more often 1-2cm deeper.

When do external hemorrhoids bother us specialists? When blood clotted in them and formed the so-called perianal thrombosis, a painful hemorrhoid. This is already a painful condition, because the external haemorrhoids are where the nerve endings are located and they do not like it when their size suddenly changes, something suddenly presses on them, or there is "inflammation" around them. Then we also treat external hemorrhoids either invasively or conservatively /medically/, with various ointments, creams or laces for hemorrhoids. The above depends on the duration of the disease and the degree of difficulty. Of course, there is the possibility of dealing with the remains of external hemorrhoids, often after childbirth, if there are overhangs, duplications which can subsequently cause hygiene problems.

Can blood clot even in internal hemorrhoids? Yes, not often, but it can. I already describe the above as complicated internal hemorrhoids. They run out, blood drainage is prevented or reduced, blood vessels become thrombosed, swelling develops, which potentiates further thrombosis and a significantly painful condition occurs. This is certainly not what we want.

Hemorrhoids in pregnancy and after childbirth

Pregnancy and hemorrhoidal disease is a separate chapter. The prevalence changes completely. Pregnant women are the most at risk group for developing haemorrhoidal disease. Statistics say that up to 85 % women have hemorrhoidal disease in the second and third trimesters of pregnancy. In addition to the above, the amount of perianal thromboses in the last 3 months of pregnancy is also increasing.

How to recognize hemorrhoids

Above we have defined the whole disease and its most at-risk groups, so let's try to say something about the treatment of hemorrhoidal disease.

Popular among patients is to visit the nearest pharmacy first and seek first aid. They buy various ointments, suppositories, creams and ointments. I'm not saying that the above won't help you as a first aid, but it certainly won't solve the problem itself, it will only postpone it. The various ointments, creams, suppositories are only there to relieve the symptoms, i.e. pain, itching, cutting or swelling. However, they do not cure the disease as such.

Internal and external hemorrhoids - symptoms

This belongs to the colorectal surgeon /proctologist/ and the whole treatment depends of course on the diagnosis. Very often it happens that patients think that they suffer from haemorrhoidal disease and yet the problem is completely different. By postponing a visit to a specialist and buying more creams, ointments, suppositories for "hemorrhoids" we are only postponing a problem that may be somewhere else entirely. In the end, it will catch up with us in a more lengthy, more difficult, more invasive form of treatment and subsequent convalescence. I also do not recommend looking for a "healing miracle for hemorrhoids" like dragon's blood or various "old wives' recipes for hemorrhoids" with the addition of alpa or aloe vera gel. You can easily get unpleasant local allergic reactions with intense itching. And you certainly don't want to have an itchy rectum all your life, especially at night when you want to sleep and visit all the proctology clinics in the country because you can't get rid of it. I would like to add that antibiotics do not treat hemorrhoids, there are no antibiotics for hemorrhoids. We have those for other diseases.

How to get rid of hemorrhoids - treatment of hemorrhoids

Let's focus on what really works and that is causal treatment, i.e. removing the cause of the disease not just the symptoms. The treatment of chronic, i.e. uncomplicated haemorrhoidal disease is targeted according to the stage of the disease and according to the recommendations based on EBM (Evidence base medicine).

In the first stage of the disease, lifestyle changes such as dietary changes and adjustments to toilet habits are often sufficient. If this does not help, and since the first stage is mainly manifested by rectal bleeding without other associated symptoms, we can resort to more invasive methods such as Barron's ligature /rubbering/ alternatively Sclerotization. Here it should be stressed that one should always mainly think of another possible cause of bleeding. Unnecessarily you will sclerotize or rubber band the "minimal" internal hemorrhoid when the transverse one is somewhere else entirely. It may be an inflammatory disease of the appendage or a malignant tumour of the appendage. More advanced stages of haemorrhoidal disease can be dealt with from simple outpatient procedures such as Barron's ligature, sclerotisation to more invasive methods designed for advanced stages of the disease namely LHP /laser haemorrhoidoplasty/ or conventional surgical removal of haemorrhoids. It is always necessary to proceed from the least invasive procedure to the more invasive one, where the patient may be burdened with complications, unnecessarily long convalescence and pain.

Rubberization of hemorrhoids - Barron's ligature

I often encounter the question whether Barron's ligature /rubberization/ is not already an outdated ineffective method of hemorrhoid treatment?

In 1963, Mr. Barron came up with the brilliant idea, what if we ligated the hemorrhoids that are there in excess and beginning to protrude outward, preventing the flow of blood and therefore oxygen into the tissue. That was a great success, and it continues to this day. This elegant method is minimally burdensome to the patient, with no need for hospitalization, with minimal complications and prompt recovery, minimizing socioeconomic burden, and if well performed, has results comparable /at earlier stages/ to invasive methods. The principle is to suction the tissue with an active vacuum /in the past it was performed without active vacuum/, trapping the tissue with an instrument and applying a tourniquet.

If the method is well indicated and correctly performed, it is rarely necessary to load more than 4 rubber bands in total. It is a painless method with minimal subjective discomfort after the procedure compared to invasive procedures. It sounds simple, but it really isn't! You are literally millimeters away from having a serious complication from both an unprofessionally performed procedure and the simple sounding procedure of loading a single rubber band. Millimeters away from having to deal with another more serious problem after the procedure due to significant pain or millimeters away from having your hemorrhoidal problem not resolved.

Sclerotherapy of haemorrhoids

Sclerotisation of haemorrhoids is a method designed for the early stages of the disease as Barron's ligature. The principle consists in the application of scleroagent to the tissue, which causes its sterile "inflammation", with subsequent shrinkage of the pathological tissue. It is also a very elegant method, with a minimum of complications, but the recurrence rate is higher compared to Barron's ligature. This method can also be used in patients on anticoagulation therapy or in polymorbid patients even in advanced stages of the disease to relieve mainly bleeding symptoms. It came to the forefront of interest again during the COVID-19 panemia when more invasive procedures were postponed.

Laser hemorrhoid surgery - golden vein

Laser hemorrhoid treatment or also LHP, laser hemorrhoidoplasty is an innovative method in which no tissue is removed, either mucous membrane or skin around the anus. This is logically associated with a faster recovery, a substantial reduction in postoperative pain compared to conventional surgical treatment with a comparable treatment outcome. The laser fibre is introduced under the tissue through tiny wounds around the anal opening directly into the haemorrhoid and the subsequent energy from the laser shrinks the haemocolic knot. Wounds and unnecessary stitches as in surgical treatment are eliminated, as everything takes place under the tissues, and if the procedure is performed correctly and there is no necrotization of the tissues, complications such as anal stenosis or incontinence with sphincter injury are eliminated. A perfect knowledge of the anatomy of the anal canal and the technique of the procedure is necessary. This method with modifications can also be used to treat stage IV haemorrhoidal disease.

Hemorrhoid surgery - golden vein

Surgery/surgical/treatment of hemorrhoidal disease. Certainly no one wants to get to that stage. Although it is a time-tested and preferred method, especially for advanced stages III and IV of the disease. But nowadays, less invasive methods are also available for these advanced stages of haemorrhoidal disease. However, it still has its place in spite of longer recovery with more frequent and severe complications after the procedure and a high rate of postoperative pain. However, this is something you definitely want to avoid.

Recommendation of a proctologist

What do I, as a specialist surgeon - proctologist, see as a problem in the treatment of hemorrhoids?
First of all, there is a high level of unprofessionalism, an example being the Barron ligature, a relatively "simple" procedure that can lead to a serious complication as I mentioned above with the subsequent solution of another more complicated problem or, on the contrary, the failure to solve the problem of haemorrhoidal disease. Very frequent wrong indication of treatment and wrong diagnosis. Indications to treat even what does not need to be treated, either in the context of unprofessionalism, poor experience or other rather amoral motivation. Some adages come to mind here: "He who does nothing can do no harm" or "No one is perfect". I agree with the above only to a very small extent. These sayings mainly refer to complications that are known to arise. However, they are not related to technology. Rather, I am writing about complications that should not happen and are related to ignorance of technique, anatomy of the anal canal, and poor experience.

And that's a problem, but it has a simple solution 🙂 We can solve it.