This distinction is important both from an etiopathogenetic and therapeutic point of view as the venous flow of the superior plexus enters the portal venous system, while the other two flow into the inferior vena cava system. Finally, remember that the three plexuses described above are in communication with each other by means of small veins that connect the blood flow.
However, when we commonly talk about hemorrhoids, we mean a more or less accentuated dilation of these venous plexuses (upper – middle – lower). Their frequency in the population is difficult to assess, but it is believed that at least 50% of people over the age of 50 suffer from hemorrhoids with no particular preference for one or the other sex.
This high frequency raises an immediate question: Cirrhosis hemorrhoids, What are the causes of hemorrhoids?
The causes are many and the most frequent is the hereditary family predisposition: it can happen that more people in the same family suffer from this disease or, more generally, from generic diseases of the veins such as varices of the lower limbs. In fact, it seems that hemorrhoids or varices are not inherited, but a certain weakness of the venous wall.
Another very frequent cause of hemorrhoids is chronic constipation or constipation because it causes violent pressure during defecation which in turn increases the force of gravity of the blood column that weighs on the hemorrhoidal plexuses.
Furthermore, the hard fecal cylinder causes trauma to the venous plexuses during its passage through the anal canal.
On the other hand, diarrhea, which causes rectal tenesmus (a feeling of discomfort), can also evoke violent contractions of the anal sphincters with a consequent increase in pressure within the hemorrhoidal plexuses.
A diet free of waste and vegetable fibers and alterations of the anal sphincter can still be primary causes of hemorrhoids, not deriving from other diseases.
Secondary causes are also of great importance: that is, when hemorrhoids are manifestations of other injuries or particular physical states. We recall Cirrhosis hemorrhoids with portal hypertension, portal vein thrombosis, abdominal tumors that compress the inferior vena cava and pregnancy.
It is obvious that in these listed cases it will certainly not be hemorrhoids that will bring the patient to the doctor. In fact, for example, Cirrhosis hemorrhoids with portal hypertension (which determines the dilation of the upper and middle hemorrhoidal plexuses because, as already mentioned, these upper and middle hemorrhoidal plexuses flow directly into the portal vein district) manifests itself with symptoms much more serious than a anal itching or a small hemorrhage after defecation.
The same applies to an abdominal tumor that compresses the vena cava (very rare).
Finally, that pregnancy and childbirth are a cause favoring hemorrhoids is known to all and the reasons are easily understood and previously analyzed.
And here we are at the symptoms or the reasons that push the patient to go to the doctor. In 70% of cases the sentinel symptom is bleeding whose characteristics are to present itself at the end of the defecation with dripping or to dirty the bright red toilet paper; rarely does anemia occur.
The remaining 30% of the symptoms that push the patient to the doctor are variously divided between itching, irritation and the fact that the subject palpates at the anal level: “something” or “a growth”.
That is, it is the prolapse of haemorrhoidal gavoccioli through the anus which usually occurs at the end of defecation and which, in most cases, resolves spontaneously. If this does not happen then it is already complications of hemorrhoids which are precisely prolapse and thrombosis.
Very rarely, thrombosis occurs in non-prolapsed hemorrhoidal plexuses or, to put it another way, prolapse is the cause of thrombosis.
It is obvious that these last two conditions, commonly called “hemorrhoid attack” lead the patient to the doctor with some urgency or even to the emergency room.
The doctor in turn, in each case of hemorrhoids that presents itself, whether simple or more complex, will carry out a careful examination that includes inspection of the anal region, palpation and rectal exploration and finally will perform the rectoscopy that allows, with a suitable instrument (the rectoscope) to visually explore the anal canal at least up to 20 cm. from the anus.
At this point the diagnosis is almost complete and we are talking about first, second and third degree hemorrhoids. For first degree hemorrhoids we mean the internal ones that are barely visible; second degree those with prolapse at the end of defecation which regresses spontaneously and third degree when the prolapse is permanent.
When the prolapse is irreducible even manually then we even speak of fourth degree hemorrhoids, but in this case, as already mentioned, we are talking about complications.
The study of a patient with hemorrhoids must be completed with the execution of a double-contrast barium enema if possible to examine the entire colon, that is, the terminal part of the intestine. This is because many other diseases (ulcerative colitis, Crohn’s disease, benign and malignant tumors) that can manifest with hemorrhoid-like symptoms, such as bleeding, must be ruled out.
Unfortunately, it can happen that bleeding through the anus is interpreted as the manifestation of hemorrhoids when instead it is the symptom of other more serious injuries.
Cirrhosis hemorrhoids: Once the diagnosis has been made more precisely, the time has come for treatment which can be divided into four forms:
- medical therapy
- sclerosing injections
- cryosurgical therapy
- surgical therapy
Medical therapy includes certain hygiene and dietary rules such as sitz baths with cold water, intake of foods rich in waste, and stool softeners accompanied by anti-inflammatory therapy and local ointments.
This treatment has a good success rate, at least symptomatic in the first two stages of hemorrhoids.
The sclerosing injections, currently no longer in use, are carried out by infiltrating the hemorrhoidal gavoccioli with sclerosing agents (5% phenol in vegetable oil) which cause sclerosis of the submucosas. This technique is imprecise and sometimes complicated by local inflammatory reactions of a moderate entity, by prostatitis. It can also be performed only in the first two stages where palliative therapy is also fairly successful.
Cryosurgery uses probes that use carbon dioxide or liquid nitrogen to produce very low temperatures (from -70 ° C to -180 ° C).
These probes, placed in contact with the hemorrhoids, cause necrosis painlessly and therefore without anesthesia. This method, after an initial success around the 1970s, is currently at the center of various criticisms as the results, both in the short and long term, are not brilliant, with the possibility of even serious complications.
The definitive surgical treatment consists in the ligation and excision of the haemorrhoidal gavoccioli. It is a technically easy surgery which however requires general anesthesia except in special cases of patients in poor general conditions due to heart disease or lung disease in which it must be performed under local anesthesia.
It requires three to five days of hospital stay and can present, in low percentages, some inconveniences such as pain, bleeding, urinary retention.
Complications that are however easily controlled with analgesics, blood coagulants and in the case of retention with bladder catheterization.
Surgery for ligation and excision of hemorrhoids is a must in cases of third and fourth type hemorrhoids after an adequate period of preoperative preparation, and finally when hemorrhoids cause anemia.
In conclusion, it can be said that hemorrhoids are a frequent disease of adulthood that progressively present themselves in different forms.
