Ano-Rectal Diseases:

Ano-Rectal Anatomy:
Anorectal area is the terminal portion of GIT
Rectum is last 12cms above anal canal
Anal canal extends from verge to levator-external sphincter complex
Dentate line is 2cms from anal verge where columnar epithelium becomes squamous

Haemorrhoids:
Hemorrhoids are an extremely common problem, especially in western countries, where surveys suggest that as much as half of the population over 40 years of age may suffer some form of mild to severe discomfort from them.

The problem is not new: hemorrhoids have been reported for thousands of years.
Considering the widespread pain and suffering as well as medical expense involved, this disease has to be dealt seriously.

What are haemorrhoids ?
Haemorrhoids, also known as piles, they are varicose veins in the canal of the anus.
Anatomy:
The hemorrhoidal plexus (or rectal venous plexus) surrounds the rectum, and communicates in front with the vesical plexus in the male, and the uterovaginal plexus in the female.
It consists of two parts, an internal in the submucosa, and an external outside the
muscular coat.

The internal plexus presents a series of dilated pouches which are arranged in a circle around the rectum, immediately above the anal orifice, and are connected by transverse branches.

Venous drainages:
The lower part of the external plexus is drained by the inferior hemorrhoidal veins into the internal pudendal vein;

A free communication between the portal and systemic venous systems is established through the hemorrhoidal.
The middle part by the middle hemorrhoidal vein which joins the hypogastric vein;

and the upper part drained by the superior hemorrhoidal vein which forms the commencement of the inferior mesenteric vein, a tributary of the portal vein.

The veins of the hemorrhoidal plexus are contained in very loose connective tissue,
So that they get less support from surrounding structures than most other veins.
Thus are less capable of resisting increased strain

When the veins of this network become
swollen with blood,
Varicosed, we call them,
“Hemorrhoids”


Factors:
associated with development of Hemorrhoids are:
Genetic predisposition (weak rectal vein walls and/or valves)
Increased venous pressure from various causes
Higher socioeconomic status
Rectal tumors - Colon malignancy

causes for incomplete evacuation of stool from the rectum
straining during bowel movements
too much pressure on the rectal veins due to poor muscle tone or poor posture.

Additional factors that can influence the course of hemorrhoids (mostly by increasing rectal vein pressure), especially for those with a genetic predisposition, are:
Obesity
Sedentary lifestyle
Hepatic disease

Constipation
Chronic diarrhea
Poor bathroom habits ( i.e. sitting for unusually long periods of time [like reading in the toilet]
Pregnancy
Postponing bowel movements
Fiber-deprived diet may be associated with bowel movement and straining

Food
Insufficient hydration (caused by not drinking enough water

or by drinking too much diuretic liquid such as coffee or cola can cause a hard stool, which can lead to hemorrhoidal irritation.

Factors-Food milk products:
An excess of lactic acid in the stool, a product of excessive consumption of milk products such as cheese, can cause irritation

Vitamin E deficiency is also a common cause.
Excessive alcohol consumption can cause diarrhea which in turn can cause hemorrhoidal irritation.

Other factors:

Spinal cord injury

Rectal surgery

Episiotomy

Anal intercourse

Epidemiology:
Frequency: In the US: Prevalence is estimated at 4.4% in the general population.
Race: Patients presenting with hemorrhoidal disease are more frequently white, from higher socioeconomic status than from rural areas.
Even in India prevalence of hemorrhoids are at a higher percentage.

Sex: No predilection is known, although men are more likely to seek treatment.
Age: External hemorrhoids occur more commonly in young and middle-aged adults than in older adults.
The prevalence of hemorrhoids increases with age, with a peak in persons aged 45-65 years.

Types:

Haemorrhoids originating either above the dentate line (internal)

Below the dentate line (external).

External Haemaorrhoids:
Occur outside of the anal verge (the distal end of the anal canal).
They are sometimes painful, and can be accompanied by swelling and irritation.
Itching, although often thought to be a symptom from external hemorrhoids, is more commonly due to skin irritation.
If the vein ruptures and a blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid.

Internal Haemorrhoids:
are those that occur inside the rectum.
As this area lacks pain receptors, internal hemorrhoids are usually not painful and most people are not aware that they have them.
Internal hemorrhoids, however, may bleed when irritated.
Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids.

internal hemorrhoids are so distended that they are pushed outside of the anus.

The anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside of the anal opening,
then supply of blood is cut off, and the hemorrhoid becomes strangulated

First-degree
(or grade 1)
piles are small swellings on the inside lining of the anal canal. They cannot be seen or felt from outside the anus.

Second-degree (or grade 2) piles are larger and stick out (or prolapse) from the anus when one goes to the toilet, but return afterwards.

Third-degree (or grade 3) piles are similar, but hang out from the anus and only return inside when pushed back with a finger.

Fourth-degree (or grade 4) piles permanently hang down from the anus and you cannot push them back inside.

Symptoms:
The common symptoms of haemorrhoids are:
Itching around the anus
Signs of blood (bright red) on toilet paper after a bowel motion
Soreness and discomfort during and immediately after a bowel motion
A visible swelling around the anus
A feeling that the bowels have not been completely emptied

In addition to the general physical examination, physicians should also perform visual inspection of the rectum, digital rectal examination, and anoscopy or proctosigmoidoscopy when appropriate.

The preferred position for the digital rectal examination is the left lateral decubitus with the patient's knees flexed toward the chest.
Topical anesthetics (eg, 20% benzocaine or 5% lidocaine ointment) may help to reduce any discomfort caused by examination.

External findings important to note include any of the following:
Redundant tissue
Skin tags from old thrombosed external hemorrhoids
Fissures
Fistulas
Signs of infection or abscess formation
Rectal or hemorrhoidal prolapse, appearing as a bluish, tender perianal mass

During the digital rectal examination, assess for any masses, tenderness, mucoid discharge or blood, and rectal tone.
Internal hemorrhoids are usually not palpable unless thrombosed.

Current guidelines from most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding.

Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of hemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.

Differential diagnosis:
Colorectal cancer: early diagnosis essential;
Inflammatory bowel disease:
Crohn's, ulcerative colitis.
Rectal prolapse
Adenomatous polyps,
Anal fissure,
Condylomata acuminata (genital warts),
perianal abscess,
Anal fistula.
Other causes of pruritus ani, e.g. threadworms, contact dermatitis

Treatment:
Proper bowel & eating habits are best preventative measures
Cold packs 1st few hours, hot sitz bath bid for 20-30 minutes
Use of high fiber diet,

Homeopathic Remedies & Treatment:


AESC, AGAR, ALOE, ARS CARB-AN, CARB-V, CAUST, COLL GRAPH, HAM, KALI-AR KALI-C KALI-S, LACH , MERC-I-R, MUR-AC LYC,NIT-AC, NUX-V, PAEON PHOS, PULS, RAT, SEP

3 AESC, ALOE, HAM, LACH, MUR-AC, RAT, SULPH
2 am-c, 2 ang, 2 bar-c, 2 bar-m, 2 brom, 2 calc, 2 calc-p, 2 carbn-s, 2 caust, 2 coll, 2 ferr, 2 ferr-ar, 2 gran, 2 graph, 2 hep, 2 iod, 2 lyc, 2 merc, 2 nit-ac, 2 paeon, 2 phos, 2 plat, 2 podo, 2 puls, 2 rhus-t, 2 sep, 2 sil, 2 ter, 2 tub
1 nux-v

Aloes:
Hemorrhoids protrude like grapes, very sore and tender, better cold water application.
Constipation with heavy
pressure in lower part of abdomen.

Aesculus hippocastanum:
In some districts it is a popular custom to carry a chestnut in the pocket as a preventive.
Anus raw, sore.. Constipation, hard, dry, knotty, white stools.
Pains long after stools.
Feels full of small sticks. Much pain after stool with prolapse.
Hemorrhoids, worse during menopause. Hemorrhoids with sharp shooting pains up the back, blind and bleeding, purple painful,external, worse standing and walking.

Aesculus glabra:
It has hard, knotty stools, very painful.
Dark purple hemorrhoids with lame back and lower limbs.
Proctitis.

Hamamellis:
Anus feels sore and raw.
Hemorrhoids, bleeding profusely with soreness.
Pulsation in rectum. Large quantities of tar-like blood in stools.
Stools: costive, hard, coated with mucus.

Collinsonia:
Has special value when given before operations, for rectal diseases.
Sense of weight and constriction. Depressed arterial tension, general atony of muscular fiber.
Pruritus in pregnancy with hemorrhoids.

Nitric acid:
Great straining, but little passes.
Bowels constipated with fissures in rectum.
Tearing pains during stools. Stools tear the anus, even though soft.
Violent cutting pains after stools, lasting for hours, walks in
agony. (Rat.) Anus, itching, eczematous or oozes moisture.
Burning in rectum after urination.
Hemorrhoids bleed easily.
irritable and exhausted.
Hemorrhages from rectum after removal of hemorrhoids.

Nux vomica:
Constipation with frequent ineffectual urging.
Stool is incomplete and unsatisfactory, Feeling as if part of stool remained unexpelled.
Constriction of rectum.
Alternate constipation and diarrhea-after abuse of purgatives.
Urging to stool felt throughout abdomen.
itching, blind hemorrhoids with ineffectual urging to stool, very painful after drastic drugs.

paeonia:
Excruciating pain at anus, continues long after stools, must rise and walk about.
Biting, itching in anus orifice swollen. Anal fissures.
Burning in anus, then internal chilliness.
Anal fistula, diarrhea with burning and internal chilliness.
Hemorrhoids, large and ulcerated. Painful ulcer, oozing offensive moisture on perineum.

Ratanhia:
Constriction or as of sharp splinters of broken glass in rectum.
Dry heat at anus with sudden knife-like stitches.
Fissure of anus with great constriction, burning like a fire.
Hemorrhoids burn like fire,temporarily relieved by cold water.
stools burn,burning pains before and after stools.
Discharge of blood from rectum with or without stools.
Stool is forced with great straining and followed by prolonged aching, burning, better hot water.
Stools must be forced with great effort, protrusion of hemorrhoids.
Oozing at anus.
Dry, itching anus.
Pinworms. (Sant., Teucr., Cina). Ascarides.

Sepia:
Bleeding at stool and fullness of rectum.
Sense of weight or ball in anus not better by stool.
Constipation obstinate, no urging for days.
Constipation, large, hard stools, cannot strain with great tenesmus.
Pains shoot up in rectum.
Dark-brown, round balls glued together with mucus.
Soft stool, difficult. Prolapsed anus. (Podo.)
Rectum is constricted and powerless, almost constant oozing from anus.
Hemorrhoids of pregnancy,prolapsing with sticking pain, bleed while walking.
Stools passed after prolonged straining, followed by cupful of jelly like yellow-white, very offensive mucus.

Acid mur:
Hemorrhoids most sensitive to all touch, even sheet of toilet paperis painful.
Hemorrhoids during pregnancy, bluish, hot with violent stitches.
Very sore hemorrhoids, better heat, protruding like a bunch of grapes.

Lachesis:
Constipation of pregnancy.
Anus feels tight, as if nothing could go through it.
Pain darting up the rectum every time he sneezes or coughs.
Hemorrhage from bowels like charred straw, black particles.
Hemorrhoids protrude, become constricted,purplish, stitches in them on sneezing or coughing.
Diarrhea from fruits and acids.

PREVENTION:
Prevention of hemorrhoids: includes drinking more fluids
Eating more dietary fiber
Exercising, practicing better posture
And reducing bowel movement strain and time.

Hemorrhoid sufferers should avoid using laxatives and should strictly limit time straining during bowel movement.
Wearing tight clothing and underwear will also contribute to irritation and poor muscle tone in the region and promote hemorrhoid development.

Straining can be lessened by defecating in a standing position, knees slightly bent.
This position seems to use the muscles of the abdomen to expel feces preventing a strain on the anus.
Washing the anus with cool water and soap may reduce the swelling and increase blood supply for quicker healing and may remove irritating fluid.

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