Hemorrhoids and Steroids

The Greek word ‘hemorrhoid’ means ‘discharging blood’ and this is indeed the most common manifestation of symptomatic hemorrhoids. However, hemorrhoids not causing symptoms are normal. Everybody has hemorrhoidal tissue consisting of shortcuts between arteries and veins arranged as a small irregularly shaped blood vessel beneath the surface of the rectum. These are technically known as hemorrhoidal complexes.

What are hemorrhoid complexes for?

Nobody knows for sure what these “vascular cushions” are for but they appear to be important for sensing fullness and pressure and for perceiving anal contents. In addition, they may support anal closure, facilitate continence, and help protect the anal sphincter from injury during defecation.

How can hemorrhoids cause problems?

Why hemorrhoids start to cause symptoms is uncertain. They may enlarge because of weakening of the supportive tissues or increased blood flow. Obesity and a sedentary life style may be contributory. The most common complications of hemorrhoids are heavy bleeding, chronic unremitting prolapse of mucosal tissue, strangulation, ulceration, and thrombosis. Hemorrhoids are graded into 4 degrees (Goligher’s classification) as the figure shows. Important to know is that painless bleeding is possible with internal hemorrhoids of any degree or size.

Classification of internal hemorrhoids. N Engl J Med 2014; 371:944-951.

How are problems with hemorrhoids diagnosed?

For all patients who present with rectal bleeding, confirmation by anorectal exam, anoscopy, flexible sigmoidoscopy, or colonoscopy should be performed. If you are reading this and have rectal bleeding, you need to see a doctor, unless you can be sure that it is only your hemorrhoids acting up.

The decision to perform a colonoscopy to examine the entire large bowel needs to be individualized and is best made by a gastroenterologist. The most serious mimic of a hemorrhoid problem could be anal cancer or the more frequent colorectal cancer. We know that there has been a sharp increase of colorectal cancer in adults as young as their 20s and 30s, with the proportion of cases found in adults under 50 increasing to 11 percent in 2013, up from 6 percent in 1990.

How are symptomatic hemorrhoids treated?

There is strong evidence from multiple randomized trials that increased fiber intake improves symptoms of hemorrhoid bleeding and mild prolapse. Although a popular myth, eating spicy food (for example, red hot chili peppers) had no effect on hemorrhoid symptoms such as irritation and itching in a controlled study.

In my own practice I have found steroid creams the most useful of all the over-the-counter (OTC) preparations. A 1% hydrocortisone cream may shrink the hemorrhoids and relieve the associated itching, and I use them as a short-term (for about a week) adjunct to an increased fiber intake.

Most patients respond to medical therapy, if not, rubber band ligation is widely recommended as the next treatment step. Both gastroenterologists and surgeons offer this type of treatment and banding can be combined with colonoscopy.

Surgical hemorrhoidectomy, the most effective treatment for hemorrhoids, is associated with significantly more pain and complications than nonoperative techniques. Accordingly, surgery should be recommended only for the small minority of patients in whom rubber-band ligation should not be performed or has failed and for those with grade IV disease or complications. A promising alternative with fewer complications is Doppler-guided transanal hemorrhoidal dearterialization (DGTHD), or THD procedure, which is offered by local surgeons in Templeton, CA and San Luis Obispo, CA.

Jacobs D. Hemorrhoids. New England Journal of Medicine. 2014 Sep 4;371(10):944-51.
Jacobs DO. Hemorrhoids: what are the options in 2018?. Current Opinion in Gastroenterology. 2017 Oct 25.


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