**5.5 Complications**

The most common complication for hemorrhoid patients is bleeding. Bleeding varies, from just spots that drip after defecation to heavy bleeding chronic. Slight bleeding may result in microcytic hypochromic anemia, while if the bleeding is profuse, patients may come down with hypovolemic shock. The profuse bleeding is an emergency, so it must be managed immediately [1–3]. Another complication is thrombosis of the veins, which can be located under the mucosa or the skin. Thrombosis of the skin or mucosa near the skin will be very painful, prompting the patient to seek treatment immediately. Prolapsed hemorrhoids accompanied by a strong anal sphincter can result in compression of the blood flow, resulting in strangulation and even necrosis [1].

## **5.6 Management**

Management of hemorrhoids depends on the stage. Management includes dietetic management and lifestyle changes (controlling risk factors), administration of drugs, and nonsurgical and surgical interventions. In grade I, II, and small III hemorrhoids, management starts with dietetic management, changing lifestyle, and administration of drugs, if those fail then nonsurgical intervention is considered. In major stages III and IV, the main choice is surgery plus dietetic management and lifestyle changes. In cases of acute thrombosis or strangulation, emergency surgery is required [8].

#### **5.7 Dietetic management and lifestyle modifications**

Patients with hemorrhoids are very prone to bleeding, and the lumps may become more swollen when the stool is hard because the defecation must be strained hard. To avoid this, the stool must be soft so that it does not cause trauma. This could be achieved by increasing a high-fiber diet or adding a bulking laxative to the diet, such as bran or methylcellulose, to facilitate defecation. A meta-analysis study showed that a high-fiber diet reduced the risk of complaints and bleeding in up to 50% of cases,

#### *Prolapsing Hemorrhoids DOI: http://dx.doi.org/10.5772/intechopen.104554*

although it did not improve complaints of prolapse, pain, and itching [11]. A highfiber diet is very effective for hemorrhoids that do not prolapse [1, 3].

Controlling the manageable risk factors by modification of lifestyle plays a role in the healing process of hemorrhoids [3]. Patients who initially do not like fiber foods should be advised to consume high fiber, drink enough water, and do regular physical activity to facilitate defecation. The recommended amount of fiber per day is 35 gr [1]. Foods that contain high fat should be avoided because they do not support the formation of large and loose stools, as well as drugs that cause constipation or even diarrhea, should also be avoided. The wrong way of defecating must be corrected. Avoid defecating by pushing too hard and sitting on the toilet for too long (smoking, reading newspapers, playing with cell phones, etc.) [2]. By squatting, it is easier to pass stool, because the puborectal muscle is more relaxed. One study shows that defecating in a squatting position only takes 1 minute, as opposed to a sitting position that needs 4–15 minutes [12]. When you are used to defecating by sitting on the toilet, by propping your feet higher, the position would be more like squatting. After defecation, the anoperineal must be clean. Remaining feces in the anal canal, for example in the anal crypts, can stimulate inflammation.
