Rectal Cancer Symptoms vs. Hemorrhoids

Most common signs or symptoms that both rectal cancer and hemorrhoids are bleeding from the rectum, more gas, stool size, and diarrhea.

Bleeding from the rectum is the most common sign or symptom that both rectal cancer and hemorrhoids share. Other shared symptoms include blood mixed with stool, a change in bowel habits (for example, more gas, change in stool size and or diarrhea), tenesmus (feeling like you need to have a bowel movement), and discomfort and/or pain during bowel movements.

Rectal cancer can have symptoms of unexplained weight loss in the absence of dieting, bowel obstruction, anemia, and fatigue. These symptoms are not usually seen with hemorrhoids. Hemorrhoids produce the symptom of pruritus (itching) in the rectal and/or anal area while rectal cancers usually do not.

Many hemorrhoids can be palpated or seen during a physical exam and are usually easy to diagnose. Rectal cancers are diagnosed by biopsy.

Rectal Cancers (sometimes termed colorectal cancers) are composed of abnormal, uncontrolled cells that may metastasize (spread) to other organ systems. Hemorrhoids, on the other hand, are blood vessels that have become swollen due to increased abdominal pressure and/or constipation/diarrhea episodes. They are located only in the rectal/anal area and do not metastasize.

Any situation that increases abdominal pressure (for example, straining for bowel movements, prolonged sitting, low fiber diet, pregnancy, and many others) is a risk factor for developing hemorrhoids. In contrast, risks for developing rectal cancer are increasing age, smoking, a family history of cancer, and other gastrointestinal diseases.

Surgery is often a necessary step in the treatment of cancers; some patients may require neoadjuvant therapy consisting of chemotherapy and radiation therapy prior to surgery. In contrast, hemorrhoids can be treated with Sitz baths, dietary changes, exercise, stool softeners, over-the-counter medication for reducing discomfort and itching. Some patients may require either surgical repair, removal of hemorrhoids, or have the hemorrhoids be treated with chemicals or lasers to shrink them.

Patients with hemorrhoids usually have a good prognosis and a normal life expectancy. Unfortunately, rectal cancer patients, especially in stages III and IV, have a fair to poor prognosis with a shortened life expectancy. People with stage III colorectal cancer have only a 53-89% 5-year survival rate, and Stage IV patients have an 11% 5-year survival rate. However, aggressive treatments have been shown to increase life expectancy in some patients.

The rectum is the lower part of the colon that connects the large bowel to the anus. The rectum's primary function is to store formed stool in preparation for evacuation. Like the colon, the three layers of the rectal wall are as follows:

• Mucosa: This layer of the rectal wall lines the inner surface. The mucosa is composed of glands that secrete mucus to help the passage of stool.
• Muscularis propria: This middle layer of the rectal wall is composed of muscles that help the rectum keep its shape and contract in a coordinated fashion to expel stool.
• Mesorectum: This fatty tissue surrounds the rectum.

In addition to these three layers, another important component of the rectum is the surrounding lymph nodes (also called regional lymph nodes). Lymph nodes are part of the immune system and assist in conducting surveillance for harmful materials (including viruses and bacteria) that may be threatening the body. Lymph nodes surround every organ in the body, including the rectum.

The American Cancer Society (ACS) estimates about 95,520 new cases of colon cancer, and 39,910 new cases of rectal cancer will occur in 2017. Males are more likely than females to develop rectal cancer (about 23,720 males to 16,190 females in 2017). The most common type of rectal cancer is adenocarcinoma (98%), which is a cancer arising from the mucosa. Cancer cells can also spread from the rectum to the lymph nodes on their way to other parts of the body.

Like colon cancer, the prognosis and treatment of rectal cancer depends on how deeply the cancer has invaded the rectal wall and surrounding lymph nodes (its stage, or extent of spread). However, although the rectum is part of the colon, the location of the rectum in the pelvis poses additional challenges in treatment when compared with colon cancer.

• Hemorrhoids are enlarged and swollen blood vessels located in the lower part of the rectum and the anus. The blood vessels become swollen due to increased pressure within them.
• Hemorrhoids usually are caused by increased pressure within the lower abdomen. Some potential causes include
• straining at the time of bowel movement (this may be due to constipation or profuse diarrhea),
  • during pregnancy
  • obesity
  • prolonged sitting,
  • rectal cancer,
  • anal intercourse
  • inflammatory bowel disease (Crohn's disease and ulcerative colitis).
• Internal hemorrhoids are located on the inside lining of the rectum and cannot be felt unless they prolapse and push through the anus opening causing pain and itching.
• External hemorrhoids are located beneath the skin on the outer aspect of the anus. Symptoms may include bleeding with a bowel movement and a mass or fullness that can be felt at the anal opening.
• A thrombosed external hemorrhoid occurs when blood within the blood vessel clots, and may cause significant pain and swelling.
• External and internal hemorrhoids are diagnosed by a physical exam and history by a health-care professional. Sigmoidoscopy or colonoscopy may be ordered to look for other causes of blood in the stool.
• Several treatments are available for hemorrhoids, and include home remedies, for example, over-the-counter (OTC) medicine like stool softeners and creams or suppositories to shrink and decrease inflammation of the hemorrhoid tissue); changes in the diet; Sitz baths; exercise; or surgery.
• Hemorrhoids can be prevented by keeping the stools soft, by regular exercise, eating a high fiber diet, drinking plenty of fluids; avoiding straining with bowel movements, and trying to avoid sitting for long periods of time, especially on the toilet.

Rectal cancer can cause many symptoms and signs that require a person to seek medical care. However, rectal cancer may also be present without any symptoms, underscoring the importance of routine health screening. Symptoms and signs to be aware of include the following:

• Bleeding (the most common symptom; present in about 80% of individuals with rectal cancer)
• Seeing blood mixed with stool is a sign to seek immediate medical care. Although many people bleed due to hemorrhoids, a doctor should still be notified in the event of rectal bleeding.
• Change in bowel habits (more gas or excessive amounts of gas, smaller stools, diarrhea)
• Prolonged rectal bleeding (perhaps in small quantities that is not seen in the stool) may lead to anemia, causing fatigue, shortness of breath, lightheadedness, or a fast heartbeat.
• Bowel obstruction
• A rectal mass may grow so large that it prevents the normal passage of stool. This blockage may lead to the feeling of severe constipation or pain when having a bowel movement. In addition, abdominal pain, discomfort, or cramping may occur due to the blockage.
• The stool size may appear narrow so that it can be passed around the rectal mass. Therefore, pencil-thin or narrow stools may be another sign of an obstruction from rectal cancer.
• A person with rectal cancer may have a sensation that the stool cannot be completely evacuated after a bowel movement.
• Weight loss: Cancer may cause weight loss. Unexplained weight loss (in the absence of dieting or a new exercise program) requires a medical evaluation.

Note that sometimes hemorrhoids (swollen veins in the anal area) can mimic the pain, discomfort, and bleeding seen with anal-rectal cancers. Individuals who have the above symptoms should get a medical exam of their anal-rectal area to be sure they have an accurate diagnosis.

Rectal cancer can cause many symptoms and signs that require a person to seek medical care. However, rectal cancer may also be present without any symptoms, underscoring the importance of routine health screening. Symptoms and signs to be aware of include the following:

• Bleeding (the most common symptom; present in about 80% of individuals with rectal cancer)
• Seeing blood mixed with stool is a sign to seek immediate medical care. Although many people bleed due to hemorrhoids, a doctor should still be notified in the event of rectal bleeding.
• Change in bowel habits (more gas or excessive amounts of gas, smaller stools, diarrhea)
• Prolonged rectal bleeding (perhaps in small quantities that is not seen in the stool) may lead to anemia, causing fatigue, shortness of breath, lightheadedness, or a fast heartbeat.
• Bowel obstruction
• A rectal mass may grow so large that it prevents the normal passage of stool. This blockage may lead to the feeling of severe constipation or pain when having a bowel movement. In addition, abdominal pain, discomfort, or cramping may occur due to the blockage.
• The stool size may appear narrow so that it can be passed around the rectal mass. Therefore, pencil-thin or narrow stools may be another sign of an obstruction from rectal cancer.
• A person with rectal cancer may have a sensation that the stool cannot be completely evacuated after a bowel movement.
• Weight loss: Cancer may cause weight loss. Unexplained weight loss (in the absence of dieting or a new exercise program) requires a medical evaluation.

Note that sometimes hemorrhoids (swollen veins in the anal area) can mimic the pain, discomfort, and bleeding seen with anal-rectal cancers. Individuals who have the above symptoms should get a medical exam of their anal-rectal area to be sure they have an accurate diagnosis.

Thrombosed external hemorrhoids are a painful condition. These occurs when a blood clot develops in a hemorrhoidal blood vessel causing swelling and inflammation.

• When a blood clot occurs in a hemorrhoid, the hemorrhoid will become even more swollen. This swelling leads to increased pain.
• The pain is usually worse with bowel movements and may increase with sitting.

A thrombosed external hemorrhoid may resolve on its own; however, this condition often needs medical care. Bleeding with a bowel movement is never normal and should prompt a visit to a health-care professional. While hemorrhoids are the most common cause of bleeding with a bowel movement, there may be other reasons for bleeding including inflammatory bowel disease, infection, and tumors.

• An internal hemorrhoid is a swollen blood vessel that arises from within the rectum above the pectinate line. It causes no symptoms unless there is bleeding with a bowel movement, or if it prolapses and can be felt externally after if protrudes through the anus.
• An external hemorrhoid arises from blood vessels that surround the anus beyond the pectinate line. They do not cause many problems unless they rapidly expand and clot. Usually this clot resolves spontaneously leaving residual skin.
• A thrombosed external hemorrhoid occurs when the blood clot that forms in an external hemorrhoid does not resolve causing increased swelling and pain within the hemorrhoidal tissue.

Rectal cancer usually develops over several years, first growing as a precancerous growth called a polyp. Some polyps have the ability to turn into cancer and begin to grow and penetrate the wall of the rectum. The actual cause of rectal cancer is unclear. However, the following are risk factors for developing rectal cancer:

• Increasing age
• Smoking
• Family history of colon or rectal cancer
• High-fat diet and/or a diet mostly from animal sources (a diet usually found in developed countries such as the United States)
• Personal or family history of polyps or colorectal cancer
• Inflammatory bowel disease

Family history is a factor in determining the risk of rectal cancer. If a family history of colorectal cancer is present in a first-degree relative (a parent or a sibling), then endoscopy of the colon and rectum should begin 10 years before the age of the relative's diagnosis or at age 50 years, whichever comes first. An often forgotten risk factor, but perhaps the most important, is the lack of screening for rectal cancer. Routine cancer screening of the colon and rectum is the best way to prevent rectal cancer.

Genetics may play a role as Lynch syndrome, an inherited disorder also known as hereditary nonpolyposis colorectal cancer or HNPCC, increases the risk of many cancers, including rectal. Although human papillomavirus (HPV) infections are more related to anal cancer and squamous cell cancers around the anus and anal canal, some studies show that they can also be related to rectal cancer. Because some rectal cancers may be associated with HPV infections, it may be possible that HPV vaccination could reduce the chance of getting some rectal cancers.

Hemorrhoids are not arteries or veins, but instead are normal blood vessels called sinusoids that are located in the walls that surround the rectum and anus. When the venous pressure within these blood vessels increases, the hemorrhoids swell and dilate, because it is more difficult for blood to empty from them. This leads to the most common symptoms of bleeding and swelling.

Common situations that increase pressure within the hemorrhoidal blood vessels and lead to abnormalities include the following.

• Straining to have a bowel movement. This may be due to constipation or diarrhea.
• Prolonged sitting, including on the toilet
• Lack of exercise
• Low fiber diet
• Obesity
• Pregnancy
• Colon cancers
• Liver disease
• Inflammatory bowel disease
• Anal intercourse
• Spinal cord injury

Surgery is likely to be the only necessary step in treatment if stage I rectal cancer is diagnosed.

The risk of the cancer coming back after surgery is low, and therefore, chemotherapy is not usually offered. Sometimes, after the removal of a tumor, the doctor discovers that the tumor penetrated into the mesorectum (stage II) or that the lymph nodes contained cancer cells (stage III). In these individuals, chemotherapy and radiation therapy are offered after recovery from the surgery to reduce the chance of the cancer returning. Chemotherapy and radiation therapy given after surgery is called adjuvant therapy.

If the initial exams and tests show a person to have stage II or III rectal cancer, then chemotherapy and radiation therapy should be considered before surgery. Chemotherapy and radiation given before surgery is called neoadjuvant therapy. This therapy lasts approximately six weeks. Neoadjuvant therapy is performed to shrink the tumor so it can be more completely removed by surgery. In addition, a person is likely to tolerate the side effects of combined chemotherapy and radiation therapy better if this therapy is administered before surgery rather than afterward.

After recovery from the surgery, a person who has undergone neoadjuvant therapy should meet with the oncologist to discuss the need for more chemotherapy. If the rectal cancer is metastatic, then surgery and radiation therapy would only be performed if persistent bleeding or bowel obstruction from the rectal mass exist. Otherwise, chemotherapy alone is the standard treatment of metastatic rectal cancer. At this time, metastatic rectal cancer is not curable. However, average survival times for people with metastatic rectal cancer have lengthened over the past several years because of the introduction of new medications.

Medications

The following chemotherapy drugs may be used at various points during therapy:

• 5-Fluorouracil (5-FU): This drug is given intravenously either as a continuous infusion using a medication pump or as quick injections on a routine schedule. This drug has direct effects on the cancer cells and is often used in combination with radiation therapy because it makes cancer cells more sensitive to the effects of radiation. Side effects include fatigue, diarrhea, mouth sores, and hand, foot, and mouth syndrome (redness, peeling, and pain in the palms of the hands and the soles of the feet).
• Capecitabine (Xeloda): This drug is given orally and is converted by the body to a compound similar to 5-FU. Capecitabine has similar effects on cancer cells as 5-FU and can be used either alone or in combination with radiation therapy. Side effects are similar to intravenous 5-FU.
• Leucovorin (Wellcovorin): This drug increases the effects of 5-FU and is usually administered just prior to 5-FU administration.
• Oxaliplatin (Eloxatin): This drug is given intravenously once every two or three weeks. Oxaliplatin has recently become the most common drug to use in combination with 5-FU for the treatment of metastatic rectal cancer. Side effects include fatigue, nausea, increased risk of infection, anemia, and peripheral neuropathy (tingling or numbness of the fingers and toes). This drug may also cause a temporary sensitivity to cold temperatures up to two days after administration. Inhaling cold air or drinking cold liquids should be avoided if possible after receiving oxaliplatin.
• Irinotecan (Camptosar, CPT-11): This drug is given intravenously once every one to two weeks. Irinotecan is also commonly combined with 5-FU. Side effects include fatigue, diarrhea, increased risk of infection, and anemia. Because both irinotecan and 5-FU cause diarrhea, this symptom can be severe and should be reported immediately to a doctor.
• Bevacizumab (Avastin): This drug is given intravenously once every two to three weeks. Bevacizumab is an antibody to vascular endothelial growth factor (VEGF) and is given to reduce blood flow to the cancer. Bevacizumab is used in combination with 5-FU and irinotecan or oxaliplatin for the treatment of metastatic rectal cancer. Side effects include high blood pressure, nose bleeding, blood clots, and bowel perforation.
• Cetuximab (Erbitux): This drug is given intravenously once every week. Cetuximab is an antibody to epidermal growth factor receptor (EGFR) and is given because rectal cancer has large amounts of EGFR on the cell surface. Cetuximab is used alone or in combination with irinotecan for the treatment of metastatic rectal cancer. Side effects include an allergic reaction to the medication and an acne-like rash on the skin. Clinical trials are underway to evaluate this antibody for the treatment of localized rectal cancer.
• Vincristine (Vincasar PFS, Oncovin): The mechanism of action of this drug is not fully known; is known to inhibit cell division.
• Panitumumab (Vectibix): This recombinant monoclonal antibody binds to human epidermal growth factor receptor (EGFR) and is used to treat colorectal cancer that has metastasized after chemotherapy treatment.

Medications are available to alleviate the side effects of chemotherapy and antibody treatments. If side effects occur, an oncologist should be notified so that they can be addressed promptly.

Home remedies do not treat rectal cancers, but some may help a patient manage side effects of the disease and treatment. For example, ginger tea may help reduce nausea and vomiting while salty crackers and sips of water may reduce diarrhea. However, patients are urged to discuss any home remedies with their doctors before using them.

Surgery

Surgical removal of a tumor and/or rectum removal is the cornerstone of curative therapy for localized rectal cancer. In addition to removing the rectal tumor, removing the fat and lymph nodes in the area of a rectal tumor is also necessary to minimize the chance that any cancer cells might be left behind.

However, rectal surgery can be difficult because the rectum is in the pelvis and is close to the anal sphincter (the muscle that controls the ability to hold stool in the rectum). With more deeply invading tumors and when the lymph nodes are involved, chemotherapy and radiation therapy are usually included in the treatment course to increase the chance that all microscopic cancer cells are removed or killed.

Four types of surgeries are possible, depending on the location of the tumor in relation to the anus.

• Transanal excision: If the tumor is small, located close to the anus, and confined only to the mucosa (innermost layer), then performing a transanal excision, where the tumor is removed through the anus, may be possible. No lymph nodes are removed with this procedure. No incisions are made in the skin.
• Mesorectal surgery: This surgical procedure involves the careful dissection of the tumor from the healthy tissue. Mesorectal surgery is being performed mostly in Europe.
• Low anterior resection (LAR): When the cancer is in the upper part of the rectum, then a low anterior resection is performed. This surgical procedure requires an abdominal incision, and the lymph nodes are typically removed along with the segment of the rectum containing the tumor. The two ends of the colon and rectum that are left behind can be joined, and normal bowel function can resume after surgery.
• Abdominoperineal resection (APR): If the tumor is located close to the anus (usually within 5 cm), performing an abdominoperineal resection and removing the anal sphincter may be necessary. Lymph nodes are also removed (lymphadenectomy) during this procedure. With an abdominoperineal resection, a colostomy is necessary. A colostomy is an opening of the colon to the front of the abdomen, where feces are eliminated into a bag.

There are several natural home remedies, for example warm Sitz baths, dietary changes, stool softeners, and exercise, to treat hemorrhoids. OTC or prescription medicine or surgery may be required to repair the hemorrhoids, for example, rubber band ligation, sclerotherapy, laser therapy, hemorrhoidectomy, and stapled hemorrhoidectomy.

Hemorrhoid symptoms of pain and itching can be treated at home by doing the following.

Warm Sitz Baths

• Sitting in a few inches of warm water three times a day for 15 to 20 minutes may help decrease the inflammation of the hemorrhoids.
• It is important to dry off the anal area completely after each Sitz bath to minimize irritation of the skin surrounding the anus.

Dietary Changes

• Increased fluid intake and dietary fiber (roughage) will decrease the potential for constipation and lessen the pressure on the rectum and anus during a bowel movement, minimizing further swelling, discomfort, and bleeding. Dietary fiber supplements also may help bulk up the stools

Stool Softeners

• Stool softeners may help. A health-care professional or a pharmacist are good resources to discuss their use.

Exercise

• Individuals with hemorrhoids should not sit for long periods of time and may benefit from sitting on an air or rubber donut available at most local pharmacies.
• Exercise is helpful in relieving constipation and in decreasing pressure on the hemorrhoidal veins. Individuals should be encouraged to have a bowel movement as soon as possible after the urge arises and not sit on the toilet for long periods of time. Once that urge passes, stools can become constipated and straining with a bowel movement may occur.

Over-the-Counter (OTC) Medications

• Many creams, ointments, and suppositories are available for symptom relief and may be used for comfort. However, they do not "cure" hemorrhoids. Often they contain a numbing medication or a corticosteroid to decrease inflammation and swelling.

Prolapsed Internal Hemorrhoids Treatment

• Most prolapsed internal hemorrhoids can be pushed back into the anus, but occasionally your health-care professional may need to reduce them by gently pushing them with constant pressure.
• If the hemorrhoids remain swollen and trapped outside the anus and they are not treated, the hemorrhoid tissue may not receive enough blood and can become infected. In such situations, surgery may be required to resolve the problem.

Thrombosed Hemorrhoids Treatment

• Thrombosed external hemorrhoids can be painful and are associated with a hard lump that is felt at the anus and cannot be pushed back inside. Most often the clot within the hemorrhoid will need to be removed with a small incision.
• After local anesthetic is placed under the skin surrounding the hemorrhoid, a scalpel is used to cut into the area and the clot is removed. There is almost instant relief of the sharp pain but a dull ache may continue.
• There may be some mild bleeding from the hemorrhoid for a couple of days. Sitz baths and over-the-counter pain medications may be recommended.
• The use of a rubber or air rubber donut may help with the pain, and preventing constipation is a priority.

Internal Hemorrhoid Treatments

Unless there is bleeding an internal hemorrhoid may have no symptoms. Once there is bleeding and/or prolapse and the diagnosis is made, home remedies are most often used to control symptoms. If bleeding increases or there is difficulty in reducing prolapsed hemorrhoids, referral to a surgeon is often made to discuss more aggressive treatment options.

External Hemorrhoid Treatment

Treatment of external hemorrhoids usually addresses the hygiene issue, where excess skin tags makes it difficult to properly clean the anus area after a bowel movement. If this becomes a significant issue, surgery can be considered to remove the hemorrhoid.

Thrombosed external hemorrhoids may require the clot removed acutely in an office or emergency/urgent care department procedure.
What surgery options are available to treat and cure hemorrhoids?

A variety of surgical options exist for persistent pain or bleeding:

• Rubber band ligation: Rubber band ligation of internal hemorrhoids can be performed in the doctor's office. The surgeon places a couple of tight rubber bands around the base of the hemorrhoidal vein, which causes it to lose its blood supply. There may be some fullness or discomfort for 1 to 2 days after the procedure, and a minor amount of bleeding may be experienced.
• Sclerotherapy: Sclerotherapy describes a procedure when a chemical is injected into the hemorrhoid, which causes it to scar and decrease in size.
• Laser therapy: Laser therapy can be used to scar and harden internal hemorrhoids.
• Hemorrhoidectomy: Hemorrhoidectomy is a surgical procedure performed in the operating room with an anesthetic agent (general, spinal or local with sedation) where the whole hemorrhoid is removed (ectomy=removal). This is the most aggressive approach and there is a markedly decreased chance of the hemorrhoids returning. There is a potential for complications with this procedure; however, these occur less than 5% of the time. Complications include infection, bleeding, and stenosis where scarring causes the anus to narrow.
• Stapled hemorrhoidectomy: Stapled hemorrhoidectomy is the newest surgical technique for treating hemorrhoids, and it has rapidly become the treatment of choice for severe hemorrhoid disease. Stapled hemorrhoidectomy is a misnomer since the surgery does not remove the hemorrhoids, but instead tightens the abnormally lax hemorrhoidal supporting tissue to prevent the hemorrhoid to prolapse downward. Stapled hemorrhoidectomy is faster than traditional hemorrhoidectomy, taking approximately 30 minutes. It is associated with much less pain than traditional hemorrhoidectomy and patients usually return to normal activities and work sooner.

Regardless of the surgery, Sitz baths and dietary suggestions for increased roughage are usually recommended.