Haemorrhoid

Haemorrhoids, also known as piles, are vascular structures in the anal canal that help with stool control in their normal state. When these structures become swollen or inflamed, they result in a condition referred to as haemorrhoidal disease.

This condition is common, affecting approximately 50% to 66% of individuals at some point in their lives, particularly between the ages of 45 and 65. The exact cause of haemorrhoids is unknown, but several risk factors, including constipation, diarrhoea, prolonged sitting, and pregnancy, are believed to contribute to their development.

Signs and Symptoms

External Haemorrhoids

External haemorrhoids occur below the dentate line and are covered by anoderm and skin, both sensitive to pain and temperature. If not thrombosed, they may cause few problems. Thrombosed external haemorrhoids, however, can be very painful, but this pain usually resolves within two to three days, although swelling may persist for a few weeks. They can cause irritation and itchiness around the anus, especially if they interfere with hygiene.

Internal Haemorrhoids

Internal haemorrhoids originate above the pectinate line and are usually painless due to the lack of pain receptors in the covering columnar epithelium. Common symptoms include painless, bright red rectal bleeding during or following defecation. Additional symptoms may include mucous discharge, perianal mass if prolapsed, itchiness, and faecal incontinence. Pain typically occurs only if the haemorrhoids become thrombosed or necrotic.

Causes

The exact cause of symptomatic haemorrhoids is unknown, though several factors are believed to play a role. These include irregular bowel habits (constipation or diarrhoea), lack of exercise, low-fibre diets, increased intra-abdominal pressure (prolonged straining, ascites, pregnancy), genetics, and ageing. Other potential risk factors include obesity, prolonged sitting, chronic cough, and pelvic floor dysfunction. Haemorrhoids are also common during pregnancy due to increased abdominal pressure from the foetus and hormonal changes.

Pathophysiology

Haemorrhoid cushions are normal anatomical structures that contribute to anal continence. They become pathological when they slide downwards or experience excessive venous pressure. The pectinate line divides internal and external haemorrhoids, which arise from the superior and inferior haemorrhoidal plexus, respectively.

Diagnosis

Haemorrhoids are typically diagnosed through physical examination. External or prolapsed haemorrhoids can be identified visually, while internal haemorrhoids may require anoscopy. A digital rectal exam can detect other potential issues like tumours or abscesses. Internal haemorrhoids are classified into four grades based on the degree of prolapse, ranging from no prolapse (Grade I) to irreducible prolapse (Grade IV).

Internal Haemorrhoid Grades

Treatment

Conservative Management

Conservative treatment involves dietary changes to increase fibre intake, maintaining hydration, and using NSAIDs for pain relief. Sitz baths may provide symptomatic relief, though evidence supporting their efficacy is limited. Topical treatments, including steroid-containing agents, may be used but should not exceed 14 days due to potential skin thinning.

Procedures

Several office-based procedures can be performed for symptomatic relief. Rubber band ligation is commonly used for Grade I to III haemorrhoids, involving elastic bands to cut off the blood supply to the haemorrhoid. Sclerotherapy involves injecting a sclerosing agent to collapse the haemorrhoidal veins. Cauterisation methods like infrared radiation and electrocautery are also options.

Surgical Interventions

For severe cases, surgical options include excisional haemorrhoidectomy, Doppler-guided transanal haemorrhoidal dearterialisation, and stapled haemorrhoidopexy. Each technique has its own indications, benefits, and potential complications.

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Self-assessment MCQs (single best answer)

What are haemorrhoids also known as?

Which of the following is a common symptom of internal haemorrhoids?

Which age group is most commonly affected by haemorrhoids?

Which of the following is NOT a risk factor for developing haemorrhoids?

Which anatomical line divides internal and external haemorrhoids?

What grade of internal haemorrhoid is characterised by prolapse upon bearing down that requires manual reduction?

What conservative treatment for haemorrhoids involves soaking in warm water?

Which office-based procedure involves using elastic bands to cut off the blood supply to the haemorrhoid?

Which of the following is a surgical intervention for severe haemorrhoids?

What is the main symptom of thrombosed external haemorrhoids?