Haemorrhoids

Haemorrhoids are defined as an abnormal swelling or enlargement of the vascular anal cushions.

Fig 1 - Haemorrhoids located in the 3, 7, and 11 o'clock positions

Fig 1 – Haemorrhoids located in the 3, 7, and 11 o’clock positions

The anal vascular cushions act to assist the anal sphincter in maintaining continence, and as such they are a normal part of a person’s anatomy. There are 3 vascular cushions in the anus, positioned at the 3-, 7- and 11- o’clock positions (when looked at with the patient in the lithotomy position, i.e. anterior is 12 o’clock).

When these cushions become abnormally enlarged that they can cause symptoms and become pathological, termed haemorrhoids.

The prevalence of haemorrhoids varies, mainly due to wrong attribution of anorectal symptoms. A review of US national data sources showed that 4% of US population complained of haemorrhoids and have a prevalence peak at age 45-65yrs.


Classification

Haemorrhoids are classified according to their size:

1st Degree Remain in the rectum
2nd Degree Prolapse through the anus on defecation but spontaneously reduce
3rd Degree Prolapse through the anus on defecation but require digital reduction
4th Degree Remain persistently prolapsed


Risk Factors

Most haemorrhoids are idiopathic, however the main risk factors for their development are excessive straining (from chronic constipation), increasing age, and raised intra-abdominal pressure (such as pregnancy, chronic cough, or ascites)

Other less common risk factors include pelvic or abdominal masses, family history, cardiac failure, or portal hypertension.


Clinical Features

Haemorrhoids typically present with painless bright red bleeding, commonly after defecation and often seen either on paper or covering the pan. Importantly, blood is seen on the surface of the stool, not mixed in. Other symptoms include:

  • Pruritus – due to chronic mucus discharge and irritation.
  • Prolapse – presenting as rectal fullness or an anal lump.
  • Soiling – due to impaired continence or mucus discharge.

Large, prolapsed haemorrhoids can thrombose. These are incredibly painful and these patients frequently present acutely as an emergency patient.

Examination will usually be normal unless the haemorrhoids have prolapsed.  So-called “external piles” are usually simple skin tags or “sentinel piles” from a fissure-in-ano.  A thrombosed prolapsed haemorrhoid will present as a purple/blue, oedematous, tense, and tender perianal mass.

Fig 2 - Types of Haemorrhoids (A) 1st Degree Haemorrhoids, as seen on endoscopy (B) 2nd Degree Haemorrhoid (C) Thrombosis and Ulceration of External Haemorrhoid

Fig 2 – Types of Haemorrhoids (A) 1st Degree Haemorrhoids, as seen on endoscopy (B) 2nd Degree Haemorrhoid (C) Thrombosis and Ulceration of External Haemorrhoid


Differential Diagnosis

It is important to exclude other cause of rectal bleeding such as malignancy, inflammatory bowel disease or diverticular disease.

Other perianal differentials to consider include fissure-in-ano, perianal haematoma, perianal abscess, skin tag, or prolapsing rectal polyps.


Investigations

A proctoscopy is typically performed to confirm the diagnosis.

Any significant / prolonged bleeding or signs of anaemia would warrant a full blood count.  A flexible sigmoidoscopy or colonoscopy may also be considered to exclude malignancy or polyps.


Management

95% of haemorrhoids can be managed conservatively, especially if asymptomatic.

Provide lifestyle advice, such as increasing daily fibre and fluid intake to avoid constipation, prescribing any laxatives if necessary. Topical analgesia (such as lignocaine gel) may also be required for pain relief (avoid any oral opioids as they can lead to constipation).

Non-Surgical

Symptomatic 1st degree and 2nd degree haemorrhoids can be treated with rubber-band ligation (RBL).  This is where the haemorrhoid is drawn into the end of a suction gun and a rubber band placed over the neck of the haemorrhoid.

The main complications of this procedure include recurrence, pain (if the band is mistakenly placed below the dentate line) and bleeding.  Bleeding usually occurs at approximately 10 days (when the band and haemorrhoid drops off).  Rarely this can be very severe and need surgical intervention.

Other options include infrared coagulation / photocoagulation, bipolar diathermy, or direct-current electrotherapy.

Often patients are not too troubled by the symptoms and simply want reassurance that the bleeding is not caused by a malignancy. Reassurance alone may therefore be sufficient for many people.

Fig 3 - Rubber-band ligation of haemorrhoids.

Fig 3 – Rubber-band ligation of haemorrhoids

A new non-surgical therapy that has gained recent popularity is haemorrhoidal artery ligation (HAL), due to an effectiveness level similar to that of surgical interventions. However, recent work suggests that rubber-band ligation still is likely to remain the preferred option for patients suffering with haemorrhoids*

*A recent multi-centre RCT found that although recurrence after HAL was lower than a single RBL, HAL was more painful than RBL, and hence patients might prefer such a course of RBL to the more invasive HAL.

Surgical

5% of patients with haemorrhoids will eventually need haemorrhoidectomy.

This is indicated if symptomatic and not responding to conservative therapies, yet unsuitable for banding / injection (mainly 3rd degree and 4th degree). Typically this is either stapled haemorrhoidectomy or Milligan Morgan haemorrhoidectomy.

The main complications of a haemorrhoidectomy are bleeding, infection, constipation, stricture, anal fissures, or faecal incontinence.  The procedure is also notoriously painful.


Complications

  • Ulceration due to thrombosis
  • Skin tags
  • Ischaemia, thrombosis, or gangrene in 4th degree internal haemorrhoids.
  • Perianal sepsis

Further Reading

Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial.
Brown SR et al., The Lancet

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