Haemorrhoids

Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the 3,7,11 positions. Haemorrhoids are said to exist when they become large, congested, and symptomatic.

Clinical features:

Painless rectal bleeding is the most common symptom
Pruritus
Pain: usually not significant unless piles are thrombosed
Soiling may occur with third or fourth degree piles


Types of haemorrhoids (EXTERNAL and INTERNAL)

External: Originate below the dentate line, prone to thrombosis, and may be painful

Internal: Originate above the dentate line, do not generally cause pain

Grading: 1 - does not prolapse. 2 - prolapses but reduces. 3 - remains out but manually replaceable. 4 - can't even manually put it back

Management: Soften stools - increase dietary fibre and increase fluid intake. Topical local anaesthetics and steroids may be used to help symptoms. Outpatient treatments: rubber band ligation superior to injection sclerotherapy. Surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments. Newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy

Acutely thrombosed external haemorrhoids: typically present with significant pain, examination reveals purplish, oedematous, tender subcutaneous perianal mass. If patient presents within 72 hours then referral should be considered for excision. Otherwise, patients can be managed with stool softeners, ice packs, and analgesia. Symptoms usually settle within 10 days.