Haemorrhoids

Question 1

What are haemorrhoids?

Answer 1

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

Question 2

Briefly describe the role and location of the vascular cushions

Answer 2

The anal vascular cushions act to assist the anal sphincter in maintaining continence.

There are three 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).

Question 3

What age group does haemorrhoids commonly affect?

Answer 3

45-65yrs.

Question 4

How are haemorrhoids classified?

Answer 4

Based on size.

Question 5

Briefly describe the classification of haemorroids

Note: based on size

Answer 5

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

Question 6

What are the risk factors for haemorrhoids?

Answer 6

The main risk factors for the development of haemorrhoids 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.

Question 7

What are the clinical features of haemorrhoids?

Note: signs and symptoms

Answer 7

Haemorrhoids typically present with painless bright red rectal 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), rectal fullness or an anal lump and soiling (due to impaired continence or mucus discharge).

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

Question 8

What are the clinical features of haemorrhoids?

Note: on examination

Answer 8

Examination will usually be normal unless the haemorrhoids have prolapsed.

A thrombosed prolapsed haemorrhoid will present as a purple/blue, oedematous, tense and tender perianal mass.

Question 9

What is shown on image A?

Answer 9

(A) 1st Degree Haemorrhoids, as seen on endoscopy

Question 10

What is shown on image B?

Answer 10

(B) 2nd Degree Haemorrhoid

Question 11

What is shown on image C?

Answer 11

(C) Thrombosed and Ulcerated External Haemorrhoid

Question 12

What investigations should be ordered for haemorrhoids?

Answer 12

Proctoscopy is typically performed to confirm the diagnosis. Any significant or prolonged bleeding or signs of anaemia would warrant a full blood count and a coagulation screen.

A flexible sigmoidoscopy or colonoscopy may also be considered to exclude malignancy in certain cases, depending on the patient’s clinical features.

Question 13

Briefly describe the conservative management of haemorrhoids

Answer 13

Nearly all haemorrhoids can be managed conservatively, especially if asymptomatic.

Ensure to provide lifestyle advice, such as increasing daily fibre and fluid intake to avoid constipation, prescribing laxatives if necessary. Topical analgesia (such as lignocaine gel) may also be required for pain relief; avoid oral opioid analgesia as this can compound any constipation and worsen symptoms.

Often patients are not too troubled by the symptoms and simply want reassurance that the cause of the bleeding is not sinister, and often this is sufficient.

Question 14

Briefly describe the non-surgical management of haemorrhoids

Answer 14

Symptomatic 1st and 2nd degree haemorrhoids can be treated with rubber-band ligation (RBL). This involves the haemorrhoid being drawn into the end of a suction gun and a rubber band placed over the neck of the haemorrhoid. This can be done either in a clinic setting or in theatre.

Question 15

What are the complications of rubber band ligation (RBL)?

Answer 15

The main complications of this procedure include recurrence, pain (if the band is mistakenly placed below the dentate line) and bleeding.

Question 16

Briefly describe the surgical management of haemorrhoids

Answer 16

Haemorrhoidal artery ligation (HAL) is one surgical option for 2nd or 3rd degree haemorrhoids, with equivocal effectiveness to other interventions (including RBL).

Around 5% of patients with haemorrhoids will eventually need a haemorrhoidectomy.This is indicated if patients are symptomatic and not responding to conservative therapies, yet unsuitable for banding or injection (mainly 3rd degree and 4th degree). Typically this is either as a stapled haemorrhoidectomy or Milligan Morgan haemorrhoidectomy.

Question 17

What are the complications of a haemorrhoidectomy?

Answer 17

The main complications of a haemorrhoidectomy are bleeding, infection, constipation, stricture, anal fissures or faecal incontinence.

Question 18

What are the complications of haemorrhoids?

Answer 18

Complications of haemorrhoids include thrombosis, ulceration or gangrene (secondary to thrombosis), skin tags or perianal sepsis.

Question 19

What differentials should be considered for haemorrhoids?

Answer 19

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, a perianal abscess or fistula-in-ano. So-called “external piles” are usually just simple skin tags or “sentinel piles” from a fissure-in-ano.