Piles (haemorrhoids)

Introduction
Haemorrhoids, commonly referred to as piles, are vascular cushions in the anal canal that become symptomatic when swollen, inflamed, or prolapsed. They are a normal anatomical structure that contributes to continence by providing a seal for the anal canal. When these cushions enlarge pathologically, they cause bleeding, discomfort, and sometimes prolapse or thrombosis.

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Anatomy and Classification

Normal anatomy

• Haemorrhoidal cushions are composed of blood vessels, connective tissue, and smooth muscle.

• Located in the submucosa of the anal canal at three primary positions: left lateral, right anterior, and right posterior.

Classification

1. By location:

   • Internal haemorrhoids: Arise above the dentate line, covered by columnar epithelium, innervated by visceral nerves (painless).

   • External haemorrhoids: Arise below the dentate line, covered by squamous epithelium, innervated by somatic nerves (painful if thrombosed).

   • Mixed haemorrhoids: Features of both.

2. By grade (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 become strangulated.

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Etiology and Risk Factors

• Chronic constipation or diarrhoea.

• Straining during defecation.

• Low-fibre diet.

• Prolonged sitting on the toilet.

• Pregnancy (increased pelvic pressure).

• Obesity.

• Aging (weakening of supporting connective tissue).

• Heavy lifting or increased intra-abdominal pressure.

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Pathophysiology
Increased pressure within the haemorrhoidal plexus leads to engorgement, stretching, and weakening of supporting tissue. This results in symptomatic haemorrhoids, which may bleed, prolapse, or thrombose.

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Clinical Features

Symptoms:

• Bright red rectal bleeding (on toilet paper, in the pan, or coating stool).

• Anal itching or irritation.

• Prolapse of tissue during defecation.

• Pain (especially with thrombosed external haemorrhoids).

• Mucus discharge and soiling (in prolapsed haemorrhoids).

Signs:

• Visual inspection: External haemorrhoids, prolapsed internal haemorrhoids.

• Digital rectal examination: May detect internal haemorrhoids (not prolapsed).

• Anoscopy: Direct visualization for diagnosis and grading.

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Differential Diagnosis

• Anal fissure

• Rectal prolapse

• Colorectal cancer

• Inflammatory bowel disease

• Polyps

• Perianal abscess

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Investigations

• Anoscopy: Gold standard for diagnosis of internal haemorrhoids.

• Proctoscopy/sigmoidoscopy/colonoscopy: Indicated if age >40, bleeding unexplained, or malignancy suspected.

• FBC: Assess for anaemia in chronic bleeding.

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Management

1. Conservative Measures (First-Line for All Grades)

• Dietary modification: Increase fibre (20–30 g/day) via diet or supplements (psyllium, methylcellulose).

• Adequate fluid intake.

• Avoid straining; respond promptly to the urge to defecate.

• Limit prolonged sitting on the toilet.

• Sitz baths (warm water immersion) for 10–15 minutes, 2–3 times daily, to relieve discomfort.

• Good anal hygiene.

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2. Medical Therapy

• Topical preparations:

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

  • Mild corticosteroids (e.g., hydrocortisone 1% cream) short-term to reduce inflammation and itching.

  • Combination products (e.g., hydrocortisone + local anaesthetic).

• Oral venoactive agents (e.g., micronized purified flavonoid fraction [diosmin/hesperidin] 500 mg twice daily) may reduce symptoms in acute flares.

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3. Office-Based Procedures (for persistent symptoms or Grade II–III)

• Rubber band ligation:

  • Most common for Grades I–III internal haemorrhoids.

  • Rubber band applied to haemorrhoid base → ischemia → sloughing.

• Infrared coagulation: Infrared light causes coagulation and fibrosis.

• Sclerotherapy: Injection of sclerosant (e.g., 5% phenol in oil) to cause fibrosis.

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4. Surgical Management (for Grade III–IV, recurrent, or complicated haemorrhoids)

• Excisional haemorrhoidectomy: Open or closed technique; definitive but more painful recovery.

• Stapled haemorrhoidopexy: Circular stapler excises mucosa above haemorrhoids and repositions them; less pain but higher recurrence risk.

• Doppler-guided haemorrhoidal artery ligation: Ultrasound probe identifies and ligates feeding arteries; less tissue excision.

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Complications

• Anaemia from chronic bleeding.

• Thrombosis (especially external haemorrhoids).

• Strangulation of prolapsed haemorrhoid → gangrene.

• Recurrence after treatment.

• Post-procedure: Pain, bleeding, infection, urinary retention.

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Prognosis
Most mild haemorrhoids improve with conservative measures. Advanced cases respond well to procedural or surgical treatment, but recurrence is possible, especially if lifestyle factors are not addressed.