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ãÔÇåÏÉ ÇáäÓÎÉ ßÇãáÉ : Hemorrhoids


Úáí ÇáÍÑÈí
04-10-2007, 09:46 AM
What are hemorrhoids?

The term hemorrhoids refers to a condition in which the veins around the anus or lower rectum are swollen and inflamed.

Hemorrhoids may result from straining to move stool. Other contributing factors include pregnancy, aging, chronic constipation or diarrhea, and anal intercourse.

Hemorrhoids are either inside the anus—internal—or under the skin around the anus—external.

What are the symptoms of hemorrhoids?

Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itching, also called pruritus ani, have similar symptoms and are incorrectly referred to as hemorrhoids.

Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days.

Although many people have hemorrhoids, not all experience symptoms. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding hemorrhoid.

Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid.

In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching.


How common are hemorrhoids¿

Hemorrhoids are common in both men and women. About half of the population has hemorrhoids by age 50. Hemorrhoids are also common among pregnant women. The pressure of the fetus on the abdomen, as well as hormonal changes, cause the hemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth. For most women, however, hemorrhoids caused by pregnancy are a temporary problem .

How are hemorrhoids diagnosed?

A thorough evaluation and proper diagnosis by the doctor is important any time bleeding from the rectum or blood in the stool occurs. Bleeding may also be a symptom of other digestive diseases, including colorectal cancer.

The doctor will examine the anus and rectum to look for swollen blood vessels that indicate hemorrhoids and will also perform a digital rectal exam with a gloved, lubricated finger to feel for abnormalities.

Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope, a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, useful for more completely examining the entire rectum.

http://digestive.niddk.nih.gov/ddiseases/pubs/hemorrhoids/images/Hemorrhoid.gif
Illustration reprinted with
permission from
the American Society
of Colon and Rectal Surgeons.
Artist: Russell K. Pearl, M.D.


To rule out other causes of gastrointestinal bleeding, the doctor may examine the rectum and lower colon, or sigmoid, with sigmoidoscopy or the entire colon with colonoscopy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve the use of lighted, flexible tubes inserted through the rectum.

What is the treatment?

Medical treatment of hemorrhoids is aimed initially at relieving symptoms. Measures to reduce symptoms include

tub baths several times a day in plain, warm water for about 10 minutes
application of a hemorrhoidal cream or suppository to the affected area for a limited time
Preventing the recurrence of hemorrhoids will require relieving the pressure and straining of constipation. Doctors will often recommend increasing fiber and fluids in the diet. Eating the right amount of fiber and drinking six to eight glasses of fluid—not alcohol—result in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding.

Good sources of fiber are fruits, vegetables, and whole grains. In addition, doctors may suggest a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or methylcellulose (Citrucel).

In some cases, hemorrhoids must be treated endoscopically or surgically. These methods are used to shrink and destroy the hemorrhoidal tissue. The doctor will perform the procedure during an office or hospital visit.

A number of methods may be used to remove or reduce the size of internal hemorrhoids. These techniques include

Rubber band ligation. A rubber band is placed around the base of the hemorrhoid inside the rectum. The band cuts off circulation, and the hemorrhoid withers away within a few days.

Sclerotherapy. chemical solution is injected around the blood vessel to shrink the hemorrhoid.

Infrared coagulation. A special device is used to burn hemorrhoidal tissue.

Hemorrhoidectomy. Occasionally, extensive or severe internal or external hemorrhoids may require removal by surgery known as hemorrhoidectomy.

How are hemorrhoids prevented?

The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Exercise, including walking, and increased fiber in the diet help reduce constipation and straining by producing stools that are softer and easier to pass.

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04-10-2007, 10:03 AM
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åãÜ jihan ÜÓå
05-10-2007, 12:51 AM
Hemorrhoids occur in everyone, they become large and cause problems in only 4 percent of the general population. Hemorrhoids that cause problems are found equally in men and women, and their prevalence peaks between 45 and 65 years of age

Anatomy of hemorrhoids

The arteries supplying blood to the anal canal descend into the canal from the rectum above and form a rich network of arteries that communicate with each other around the anal canal. Because of this rich network of arteries, hemorrhoidal blood vessels have a ready supply of arterial blood. This explains why bleeding from hemorrhoids is bright red (arterial blood) rather than dark red (venous blood), and why bleeding from hemorrhoids occasionally can be severe. The blood vessels that supply the hemorrhoidal vessels pass through the supporting tissue of the hemorrhoidal cushions

The anal veins drain blood away from the anal canal and the hemorrhoids. These veins drain in two directions. The first direction is upwards into the rectum, and the second is downwards beneath the skin surrounding the anus. The dentate line is a line within the anal canal that denotes the transition from anal skin (anoderm) to the lining of the rectum

Formation of hemorrhoids

If the hemorrhoid originates at the top (rectal side) of the anal canal, it is referred to as an internal hemorrhoid. If it originates at the lower end of the anal canal near the anus, it is referred to as an external hemorrhoid. Technically, the differentiation between internal and external hemorrhoids is made on the basis of whether the hemorrhoid originates above or below the dentate line -internal and external, respectively

As discussed previously, hemorrhoidal cushions in the upper anal canal are made up of blood vessels and their supporting tissues. There usually are three major hemorrhoidal cushions oriented right posterior, right anterior, and left lateral. During the formation of enlarged internal hemorrhoids, the vessels of the anal cushions swell and the supporting tissues increase in size. The bulging mass of tissue and blood vessels protrudes into the anal canal where it can cause problems. Unlike with internal hemorrhoids, it is not clear how external hemorrhoids form

http://images.medicinenet.com/images/illustrations/hemorrhoid.jpg

What causes hemorrhoids

It is not known why hemorrhoids enlarge. There are several theories about the cause, including inadequate intake of fiber, prolonged sitting on the toilet, and chronic straining to have a bowel movement (constipation). None of these theories has strong experimental support. Pregnancy is a clear cause of enlarged hemorrhoids though, again, the reason is not clear. Tumors in the pelvis also cause enlargement of hemorrhoids by pressing on veins draining upwards from the anal canal

One theory proposes that it is the shearing (pulling) force of stool, particularly hard stool, passing through the anal canal that drags the hemorrhoidal cushions downward
Another theory suggests that with age or an aggravating condition, the supporting tissue that is responsible for anchoring the hemorrhoids to the underlying muscle of the anal canal deteriorates. With time, the hemorrhoidal tissue loses its mooring and slides down into the anal canal

One physiological fact that is known about enlarged hemorrhoids that may be relevant to understanding why they form is that the pressure is elevated in the anal sphincter, the muscle that surrounds the anal canal and the hemorrhoids
The anal sphincter is the muscle that allows us to control our bowel movements. It is not known, however, if this elevated pressure precedes the development of enlarged hemorrhoids or is the result of the hemorrhoids. Perhaps during bowel movements, increased force is required to force stool through the tighter sphincter. The increased shearing force applied to the hemorrhoids by the passing stool may drag the hemorrhoids downward and enlarge them


First-degree hemorrhoids
Hemorrhoids that bleed but do not prolapse

Second-degree hemorrhoids
Hemorrhoids that prolapse and retract on their own -with or without bleeding

Third-degree hemorrhoids
Hemorrhoids that prolapse but must be pushed back in by a finger

Fourth-degree hemorrhoids
Hemorrhoids that prolapse and cannot be pushed back in. Fourth-degree hemorrhoids also include hemorrhoids that are thrombosed (containing blood clots) or that pull much of the lining of the rectum through the anus



What is new in hemorrhoids


Stapled hemorrhoidectomy. This is the newest surgical technique for treating hemorrhoids. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids but, rather, the abnormally lax and expanded hemorrhoidal supporting tissue that has allowed the hemorrhoids to prolapse downward

For stapled hemorrhoidectomy, a circular, hollow tube is inserted into the anal canal. Through this tube, a suture (a long thread) is placed, actually woven, circumferentially within the anal canal above the internal hemorrhoids. The ends of the suture are brought out of the anus through the hollow tube. The stapler (a disposable instrument with a circular stapling device at the end) is placed through the first hollow tube and the ends of the suture are pulled. Pulling the suture pulls the expanded hemorrhoidal supporting tissue into the jaws of the stapler. The hemorrhoidal cushions are pulled back up into their normal position within the anal canal. The stapler then is fired. When it fires, the stapler cuts off the circumferential ring of expanded hemorrhoidal tissue trapped within the stapler and at the same time staples together the upper and lower edges of the cut tissue


Internal Hemorrhoids in Anal Canal
http://images.medicinenet.com/images/illustrations/hemorrhoid_fig1.jpg

Hollow Tube Inserted into the Anal Canal
and Pushing up the Hemorrhoids
http://images.medicinenet.com/images/illustrations/hemorrhoid_fig2.jpg

Suturing the Anal Canal through the Hollow Tube
http://images.medicinenet.com/images/illustrations/hemorrhoid_fig3.jpg


Bringing Expanded Hemorrhoidal Supporting Tissue
into the Hollow Tube by Pulling on Suture
http://images.medicinenet.com/images/illustrations/hemorrhoid_fig4.jpg

Hemorrhoids Pulled Back Above Anal Canal after Stapling
and Removal of Hemorrhoidal Supporting Tissue
http://images.medicinenet.com/images/illustrations/hemorrhoid_fig5.jpg

During stapled hemorrhoidectomy, the arterial blood vessels that travel within the expanded hemorrhoidal tissue and feed the hemorrhoidal vessels are cut, thereby reducing the blood flow to the hemorrhoidal vessels and reducing the size of the hemorrhoids. During the healing of the cut tissues around the staples, scar tissue forms, and this scar tissue anchors the hemorrhoidal cushions in their normal position higher in the anal canal. The staples are needed only until the tissue heals. They then fall off and pass in the stool unnoticed after several weeks. Stapled hemorrhoidectomy is designed primarily to treat internal hemorrhoids, but if external hemorrhoids are present, they may be reduced as well

Stapled hemorrhoidectomy is faster than traditional hemorrhoidectomy, taking approximately 30 minutes. It is associated with much less pain than traditional hemorrhoidectomy and patients usually return earlier to work. Patients often sense a fullness or pressure within the rectum as if they need to defecate, but this usually resolves within several days. The risks of stapled hemorrhoidectomy include bleeding, infection, anal fissuring (tearing of the lining of the anal canal), narrowing of the anal or rectal wall due to scarring, persistence of internal or external hemorrhoids, and, rarely, trauma to the rectal wall

Stapled hemorrhoidectomy was first used in Europe in the mid 1990's and there has been increasing, worldwide usage in recent years. If results continue to be good with more experience and longer follow-up of patients, stapled hemorrhoidectomy is likely to become the mainstay of surgical therapy for symptomatic, prolapsing hemorrhoids

Hemorrhoids at a Glance

Internal hemorrhoids are clumps of tissue within the anal canal that contain blood vessels, muscle, and elastic fibers. External hemorrhoids are enlarged blood vessels surrounding the anus

Internal hemorrhoids cause problems when they enlarge. The cause of the enlargement is not known

Complications of internal hemorrhoids include bleeding, anal itchiness, prolapse, incarceration, and gangrene. Pain is not common

The primary complication of external hemorrhoids is pain due to blood clotting in the hemorrhoidal blood vessels

When dealing with hemorrhoids, it is important to exclude other diseases of the anus and rectum that may cause similar symptoms such as polyps, cancer, and diseases of the skin

Treatment of hemorrhoids includes over-the-counter topical medications, sclerotherapy, rubber band ligation, heat coagulation, cryotherapy, anal dilation, Doppler ligation, sphincterotomy, and surgical hemorrhoidectomy

The newest treatment for hemorrhoids is stapled hemorrhoidectomy

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05-10-2007, 02:33 AM
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