Haemorrhoids

Question 1

Define haemorrhoids

Answer 1

Enlargement and engorgement of anal vascular cushions (on the left lateral and right anterior and posterior borders of the anal canal), that physiologically contribute to anal closure. They tend to protrude, bleed or prolapse in the anal canal

Question 2

How are haemorrhoids classified?

Answer 2

External Haemorrhoids: •Distal to the dentate line

Internal Haemorrhoids: Proximal to the dentate line:
• Grade 1: Protrusion is limited to within the anal canal
•Grade 2: Protrudes beyond the anal canal; spontaneously reduces on cessation of straining
• Grade 3: Protrudes outside the anal canal; reduces fully on manual pressure
• Grade 4: Protrudes outside the anal canal and is irreducible

Question 3

What are the causes/risk factors of haemorroids?

Answer 3

• unknown aetiology
• age between 45-65 years
• constipation
• pregnancy or space-occupying pelvic lesion
• hepatic insufficiency
• ascites
• portal hypertension

Question 4

What are the symptoms of haemorrhoids?

Answer 4

• Commonly asymptomatic
• Bleeding, usually bright red on toilet paper or dripping into the pan
• Blood never mixed with stool
• Itching and Anal Lumps
• Severe Pain: External haemorrhoids that have become thrombosed

*Absence of red flags: FLAWS, change in bowel habit, mucus in the stool, dark coloured stool (blood mixed)

Question 5

What are the signs of haemorrhoids?

Answer 5

DRE:
• Inspection: 1st and 2nd grade are not usually visible. External, 3rd and 4th grade can be seen
• On insertion of the finger, the lumps may be felt in the anal canal

Question 6

What investigations are carried out for haemorrhoids?

Answer 6

• anoscopy - allows visualisation of haemorrhoids, most noticeable on straining
• FBC - to rule out anaemia if severe or persistent
• sigmoidoscopy - to exclude rectal sources of bleeding
• stool for occult haem - positive

Question 7

What is the management for haemorrhoids?

Answer 7

Conservative: (Grade 1) 
• High fibre diet 
• High fluid intake 
• Laxatives 
• Topical local anaesthetics 
• Shot-term corticosteroid creams
• Prolapsed or thrombosed haemorrhoids: Analgesia, ice-packs and laxatives. Pain resolves in 2-3 weeks. 

Medical: (Grade 2 or 3; Grade 1 when other measures fail)
• Injection Sclerotherapy: 5% phenol in almond oil is injected above the dentate line (no sensory fibres) into the submucosa above a haemorrhoid. Inflammation, with subsequent fibrosis resulting in mucosal healing.
• Banding: Barron’s bands are applied just proximal to the haemorrhoid. Tissue falls away after 2–3 days, leaving a small ulcer to heal. Higher cure rates but is more painful.
• Infrared coagulation: Vessels coagulated; mucosa tethered to submucosa.
• Bipolar Diathermy Causes coagulation and fibrosis.

Surgical: Symptomatic Grade 3 and 4 haemorrhoids.
• Milligan-Morgan Open Haemorrhoidectomy
• Stapled Haemorrhoidectomy

Question 8

What are the complications of haemorrhoids?

Answer 8

• Bleeding, thrombosis and gangrene
• From injection sclerotherapy: prostatitis, sepsis and abscesses
• From surgery: pain, bleeding, incontinence due to sphincter damage