What is Hemorrhoids (Hemorrhoidal Disease)?

Our gastrointestinal system (Gastrointestinal system) is a set of organs with vital functions such as taking, grinding and digesting foods starting from the mouth and extending to the anus.

The anus is the last part of the digestive system. Due to its anatomical structure and complex features such as contraction and relaxation during defecation, the anus has extremely important effects on our comfort in our daily life.
Hemorrhoids are natural anatomical structures found in all living things, located in the area defined as the anus in this system. They also have invaluable contributions to the formation of this mechanism, which is described as "continence" in medicine, such as bowel movements and holding gas. Because of these functions, they can be thought of as the gasket of the faucet. Hemorrhoids is the name of a normal anatomical structure, that is, it is not a disease. It is found normally in a newborn baby and an elderly individual. In general surgery practice, when there is a diseased condition such as bleeding, sagging or clot formation, the present picture is expressed as "hemorrhoidal disease". Due to their structure, they can also be defined as a collection of venous (vein) blood vessels. The fact that they are composed of vascular structures reveals the logic of the patient's complaint of bleeding in the problems experienced with this structure. As will be explained in the following parts of the presentation, the formation of thrombosis (clot) due to blood pooling in these vascular structures also occurs within the same logic.
The entire gastrointestinal tract from the mouth to the anus is covered with a wet-moist layer called the “mucosa”. This layer ensures the absorption of digested food and also covers the muscle layer that provides the advancement of food. The mucosal barrier is also present as a thin layer on the hemorrhoids.
Although straining in normal defecation mechanics, all structures in the anal canal show downward extension-sagging at certain rates. It is considered normal in a healthy individual without this disease. During this sagging, hemorrhoids also show partial displacement from the inside out. In the case of hemorrhoidal disease, this sagging complaint becomes more pronounced.

What is Internal Hemorrhoids?

The anus is the last part of the digestive system. Due to its anatomical structure and complex features such as contraction and relaxation during defecation, the anus has extremely important effects on our comfort in our daily life. Hemorrhoids are vascular formations found in this structure, which we call the anus. It has very important tasks such as the complete closure of the breech and thus preventing the leakage of gas and stool (stool). 

Hemorrhoids are divided into internal and external hemorrhoids. In daily practice, internal hemorrhoids are encountered more frequently due to complaints such as rectal prolapse, pushing in by hand, and bleeding.
Internal hemorrhoids are located just inside the anus and cannot be seen from the outside. However, if they get sick, sagging occurs and these internal hemorrhoids become visible from the outside.
Internal hemorrhoids, whose general appearance is in the form of thin vascular structures wrapped around each other, are located in the form of buds at 3-7-11 o'clock in a normal individual in the supine position. These bud-shaped blood vessels have the characteristics of venous blood vessels. Swelling (edema) and tension may occur in these vascular structures in cases such as constipation, excessive diarrhea, feeding with poor fiber foods, and frequent consumption of fermented beverages. With the improvement of the current situation, this edema regresses spontaneously without the need for any treatment and the problem is resolved. Sometimes this situation shows a chronic (long-term) course and complaints such as sagging and bleeding may occur in these hemorrhoids, which we also describe as symptoms of hemorrhoidal disease.

The first sign of the disease in internal hemorrhoids is bleeding. Generally, bleeding occurs in the form of drips from the anus with or immediately after the stool. Bleeding is seen as the first sign of the disease in internal hemorrhoids in the early period. The fact that internal hemorrhoids become visible from the outside of the anus (due to sagging) means that the disease has progressed. 


What is External Hemorrhoids?

The anus is the last part of the digestive system. Due to its anatomical structure and complex features such as contraction and relaxation during defecation, the anus has extremely important effects on our comfort in our daily life. Hemorrhoids are vascular formations found in this structure, which we call the anus. It has very important tasks such as the complete closure of the breech and thus preventing the leakage of gas and stool (stool).

Hemorrhoids are divided into internal and external hemorrhoids. In daily practice, internal hemorrhoids are encountered more frequently due to complaints such as rectal prolapse, pushing in by hand, and bleeding. In some cases, there may be sudden-onset swellings that appear on the skin near the anus, not from the inside out, and these swellings originate from the anatomical structures we call "external hemorrhoids".
There is a critical area just outside the breech. This area, which is called "Anoderm" in medicine, is an extremely sensitive area that does not contain sweat and hair glands. External hemorrhoids are located exactly in this area in their normal subcutaneous localization. Normally, they are not visible from the outside.
It usually occurs as a sudden onset of swelling in this sensitive area called anoderm in the breech, after excessive straining, prolonged diarrhea, sitting for too long, and sometimes heavy exercise (in the form of lifting weights). This condition is referred to as “peri anal hematoma” or “acute thrombosed external hemorrhoids” in medicine. Swelling and pain due to this swelling are more prominent in this disease rather than the complaints such as bleeding and sagging due to internal hemorrhoids, which are frequently encountered in daily practice.

When left to its natural process, within a period of about 1-3 weeks, this hematoma (blood clot) first softens and then disappears, leaving a skin fold behind. If it can be eliminated with a simple surgical intervention in the initial period, disease recurrence (at least in this area) disappears in the following periods.

What are the Symptoms of Hemorrhoids (Hemorrhoidal Disease)?

There are 3 important symptoms in hemorrhoidal disease. These are bleeding, sagging (swelling) and pain. These three symptoms are directly related to the fact that the complaints are caused by internal or external hemorrhoids and the current stage of the disease.
Bleeding: It is a bleeding that is in the form of dripping after the toilet and can sometimes be in the form of gushing depending on the size of the torn hemorrhoidal pouch (breast). Usually, internal hemorrhoids also occur due to the trauma of a hard stool. The first symptom of hemorrhoids, which are composed of vascular structures, is bleeding. Bleeding is seen in all stages in the grading of internal hemorrhoids and staging from 1 to 4. The complaint of bleeding can be much more pronounced and long-lasting, especially in patients using blood thinners.

Prolapse: It is a complaint that occurs when internal hemorrhoids protrude from the anus. In normal defecation, there is much more drooling than with straining. The degree of sagging also provides staging. For example, a hemorrhoid that goes in by itself is called stage 2, while hemorrhoids that the patient can only push on the hand are called stage 3 hemorrhoids, which cannot be pushed even with the hand and always stays outside, is called stage 4 hemorrhoidal disease. Dryness, irritation and discharge in the anus due to sagging are ongoing symptoms.
Pain: In hemorrhoidal disease, if there is a thrombosed external hemorrhoid or if there is a thrombosis or clot formation originating from internal hemorrhoids, pain also occurs, if these conditions are not present, pain is not a common symptom. Pain in the anal region, especially after defecation and lasting for hours, is usually seen due to acute anal fissure (breech fissure). Since in this disease, a fold occurs on the skin just outside the anus, this situation is felt by our patients as breast formation and is confused with hemorrhoidal disease.

Itching: It is another common symptom in hemorrhoidal disease. Depending on the protruding pouch (breast), there is a discharge from the anal canal and in this case it causes itching.

How is Hemorrhoids (Hemorrhoidal Disease) Diagnosed?

Physical examination is usually sufficient for the diagnosis of hemorrhoidal disease. The diagnosis of the disease can be made in the examinations of patients with complaints such as bleeding, sagging pain and itching, and a series of examinations are carried out to rule out other diseases that may be confused with this disease in the next stage.

Prolapse from the breech or, as our patients say, breast formation is a condition that can be easily seen from the outside. With a device called an anoscope to be used during this examination, the condition of internal hemorrhoids can be clearly seen and evaluated. It is also possible to intervene with these devices. Generally, in patients who have been left untreated for a long time, sagging progresses and internal and external hemorrhoids show a (combined) sagging position. In these patients, with a careful examination, it should be carefully determined whether the current situation is an breech prolapse (prolapse ani) by pushing the patient during the examination if necessary.

It is important for the patient to be strained during the examination, and if this cannot be achieved, a small enema to be administered and the examination immediately after defecation is important for an objective evaluation of the disease. In this way, sagging pouches and bleeding over the pouches can be clearly evaluated. It should not be forgotten that accurate staging is critical for the correct treatment of the disease.Immediately after the diagnosis of the patient, it should be shown that among the complaints in the differential diagnosis, colon and rectal cancers in which the complaints of bleeding along with stool are not present. For this purpose, all patients to be treated for hemorrhoidal disease should be evaluated colonoscopically and the presence of a possible accompanying cancer should be excluded.

Hemorrhoids (Hemorrhoidal Disease) Treatment Methods

Hemorrhoids are normal anatomical structures that have important duties in keeping gas and stool in our body. In cases such as prolonged constipation, diarrhea, fiber-poor diet and bad toilet habits, bleeding and sagging (breast formation) occur in hemorrhoids, that is, hemorrhoidal disease occurs.
The primary treatment of hemorrhoidal disease is dietary adjustments, correction of toilet habits and medical treatment.
There are many drugs that can be used in medical treatment. Among these drugs, drugs that increase venous blood circulation and thicken the vessel wall can be used effectively to reduce the patient's symptoms.
When all these applications are performed in a combined way, a significant number of patients recover without the need for surgical treatment. However, surgical treatment comes to the fore in the disease that persists despite these applications.
 
Current Methods Applied in the Surgical Treatment of Hemorrhoids (Hemorrhoidal Disease)

Classical Hemorrhoidectomy
• Although it was described a long time ago, it is still a popular treatment method. The most important advantage is that it has the lowest recurrence (recurrence of the disease) rate. It is a technique that is often used in patients with a more prominent complaint of sagging. In this method, the entire diseased pack is removed using surgical instruments. Today, energy tools are used while applying this method, and thus, the post-operative pain is tried to be minimized.
Band Ligation (Stranging Method)
• The diseased hemorrhoid nozzle is vacuumed into a gun-shaped aspirator with a rubber band at the end, and then the gun is fired to suffocate the hemorrhoid pack with the band. This band is excreted through the feces with the melting of the hemorrhoidal pouch that it has suffocated in about 3 weeks. It is a comfortable treatment method that can be applied practically without the need for anesthesia in experienced hands and without pain after the procedure if placed in the appropriate area.
Laser Hemorrhoidopexy
• It is used in patients where sagging complaints are not prominent, but rather bleeding complaints are at the forefront. With the laser device, the diseased pouch (breast) is entered and the ignition is made and the hemorrhoidal pouch is extinguished. Since there is no injury at the junction of the breech and the skin, postoperative pain is almost non-existent. It gives satisfactory results in experienced hands in patients with suitable disease stage.
Doppler Guided Hemorrhoidal Artery Ligation (DG-HAL)
• There is a hemorrhoidal vein with an anascope with a Doppler device (ultrasound device for detecting arterial flow) at its tip, and the hemorrhoid is extinguished by connecting the vein through the same device. It is also an application that allows sagging packages to be hung up. Just like in laser application, when used in appropriate patient group, pain is almost non-existent after this surgical method.
HeLP (Hemorrhoid Laser Procedure) Method