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Tuesday, August 12, 2025

Haemorrhoids (piles)


Definition

Haemorrhoids are vascular cushions in the anal canal that become enlarged, inflamed, or prolapsed, causing symptoms such as bleeding, pain, itching, or prolapse. They are classified as internal (above the dentate line) or external (below the dentate line).

Anatomy and Classification

1. Types

  • Internal haemorrhoids: Covered by columnar epithelium; visceral innervation (no pain unless thrombosed or prolapsed)

  • External haemorrhoids: Covered by squamous epithelium; somatic innervation (can be painful when thrombosed)

2. Grades of Internal Haemorrhoids

  • Grade I: Bulge into the lumen but do not prolapse

  • Grade II: Prolapse during defecation but reduce spontaneously

  • Grade III: Prolapse during defecation and require manual reduction

  • Grade IV: Irreducible prolapse, may be strangulated

Etiology and Risk Factors

  • Chronic constipation or diarrhea

  • Straining during defecation

  • Prolonged sitting on the toilet

  • Low-fiber diet

  • Pregnancy

  • Obesity

  • Aging (weakening of supporting tissues)

Pathophysiology

Haemorrhoids develop due to increased pressure in the hemorrhoidal venous plexus, leading to vascular dilatation, engorgement, and prolapse of supporting tissue. Internal haemorrhoids are usually painless due to visceral innervation; external haemorrhoids can be painful when thrombosed.

Clinical Features

Internal haemorrhoids

  • Painless bright red rectal bleeding (on toilet paper or coating stool)

  • Mucus discharge

  • Prolapse (depending on grade)

  • Pruritus ani

External haemorrhoids

  • Painful swelling near anus

  • Acute severe pain with thrombosis

  • Bleeding possible if ulcerated

Diagnosis

  • History and examination: Symptoms, bowel habits, risk factors

  • Inspection: Prolapsed haemorrhoids, external lumps

  • Digital rectal examination: Assess tone, exclude masses (may not detect high internal haemorrhoids)

  • Anoscopy/proctoscopy: Visualize internal haemorrhoids and grade them

  • Exclude other causes of rectal bleeding (fissures, colorectal cancer, polyps) especially in older patients or those with red flag symptoms

Management

Management depends on grade, severity, and presence of complications.

1. Conservative Measures (First-line for all grades)

  • Increase dietary fiber (20–30 g/day) and fluid intake

  • Avoid straining and prolonged sitting on the toilet

  • Regular exercise

  • Prompt response to urge to defecate

  • Warm sitz baths for 10–15 minutes, 2–3 times daily for symptom relief

2. Medical Treatment

Topical preparations – for short-term relief of symptoms:

  • Local anesthetics (e.g., lidocaine 5% ointment) – for pain relief

  • Mild corticosteroids (e.g., hydrocortisone 1% cream or suppository) – for inflammation, short-term use (max 7 days)

  • Astringents/protectants (e.g., zinc oxide, witch hazel) – soothe and protect mucosa

Oral venoactive drugs (flavonoids, e.g., micronized purified flavonoid fraction) – may reduce bleeding and discomfort in some cases

3. Office-based Procedures (for Grade I–III not responding to conservative care)

  • Rubber band ligation (most common) – elastic band applied to base of internal haemorrhoid to cut off blood supply; haemorrhoid sloughs off in 5–7 days

  • Infrared coagulation – coagulates tissue, causing scarring and fixation

  • Sclerotherapy – injection of sclerosant to cause fibrosis

4. Surgical Treatment (for Grade III–IV or complicated cases)

  • Haemorrhoidectomy – excision of haemorrhoidal tissue; indicated for large, symptomatic haemorrhoids or recurrent thrombosis

  • Stapled haemorrhoidopexy – repositions prolapsed haemorrhoids and reduces blood flow; less pain but higher recurrence risk

  • Thrombectomy – for acute painful thrombosed external haemorrhoids (best within 48–72 hours)

Complications

  • Thrombosis (external or internal)

  • Strangulation of prolapsed haemorrhoids

  • Anemia from chronic bleeding

  • Infection (rare)

  • Recurrence

Prognosis

  • Most cases respond to lifestyle changes and office-based procedures

  • Recurrence is possible, particularly if risk factors persist

  • Surgical outcomes are generally good but associated with postoperative pain and recovery time




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