Hemorrhoids

“What’s up, Dave? You don’t look happy!”

“Doc, its my hemorrhoids again!”

Dave has had symptoms of haemorrhoids for sometime. His main complaints have been bright rectal bleeding on the toilet paper and itching. About five years ago he was investigated for other colon and rectal problems and nothing abnormal was found.

He has been able to control the symptoms by using high fibre diet, having regular bowel movements, application of ointment, taking care of local hygiene and hot baths. He resists any temptation to strain at defecation.

Generally speaking, when patients complain about hemorrhoids, they really mean they have a problem in the rectal area. Besides hemorrhoids, one has to keep in mind conditions like: fissure, fistula, infection (abscess), inflammation of the rectum (proctitis), polyps, and cancer.

Like a good detective, the physician can eliminate these conditions by taking a careful history and do a physical examination – including the dreaded digital rectal examination. Patients also need tests like flexible sigmoidoscopy (examination of the rectum and distal colon) and in some instances colonoscopy (full examination of the colon).

“So Dave, what has changed?

This time Dave has painless bright rectal bleeding not only on the toilet paper but also outside of the stool. Blood drips after a bowel movement. Dave has been advised in the past not to ignore any bleeding from the rectum. Painless bright rectal bleeding (usually with or following bowel movements) immediately warns a physician to check for cancer.

“Doc, does every patient with rectal bleeding require colonoscopy to rule out cancer?”

No. I use age 40 as a cut off point. Patients under 40, who have no personal or family history of colon polyps or cancer or their bleeding is not associated with diarrhoea then I advise them to have flexible sigmoidoscopy as the first line of investigation. This is an office procedure requiring less bowel preparation and no sedation. It examines 60-cm. of distal colon and rectum.

Five years ago, Dave had a flexible sigmoidoscopy and this was normal except for internal hemorrhoids. Now Dave is over 40, and should undergo colonoscopy. This is a same day procedure in hospital, requiring full bowel preparation a day before, and sedation during the procedure.

Dave returns to the office after the colonoscopy. This is normal except for internal hemorrhoids. Since Dave continues to bleed off and on, he requires more than conservative (high fibre diet, no straining, local hygiene, ointment, hot bath) management.

“Doc, what are my options?”

Dave’s options depend on the size and the type of the hemorrhoids. External hemorrhoids usually require no treatment unless there is a painful blood clot in the blood vessels. This can be drained in the office under local anaesthetic with almost instant relief.

Internal hemorrhoids vary in size and symptoms. Grade 1 internal hemorrhoids do not prolapse. Grade 2 internal hemorrhoids prolapse on defecation but reduce spontaneously. Grade 3 internal hemorrhoids prolapse and require manual reduction. Grade 4 internal hemorrhoids prolapse and cannot be reduced.

Barron’s rubber band ligation is recommended as a first line treatment for Grades 1 and 2 and Grade 3 that do not respond to diet or local preparations, says an article in the Canadian Journal of Surgery. It says that rubber band application is an office procedure that does not require general anaesthetic and time off work. It is associated with fewer complications and less pain.

Surgical removal of hemorrhoids under general anaesthetic should be reserved for Grade 4 and some Grade 3 patients who do not respond to rubber band ligation. Recovery period is prolonged and more painful than rubber band ligation.

Dave has Grade 2 internal hemorrhoids and has successful rubber band ligation in the office. Dave is a happy man again!


This series of articles explore the health problems of Dave and his family. They are composite characters of a typical family with health problems.

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