Haemorrhoids

Definition | Aetiology | Pathophysiology | Risk Factors | Signs and Symptoms | Investigations | Management

Definition

Haemorrhoids, also known as piles, are swollen vascular structures in the anal canal. They may be internal (above the dentate line) or external (below the dentate line), often leading to symptoms of bleeding, discomfort, and prolapse.

Aetiology

• Increased intra abdominal pressure: due to chronic constipation, straining, or prolonged sitting.
• Pregnancy: increased venous pressure and hormonal changes contribute to haemorrhoid formation.
• Portal hypertension: leads to engorgement of rectal veins.
• Age related degeneration: weakening of supportive tissues in the anorectal region.
• Low fibre diet: leads to hard stools and increased straining.

Pathophysiology

• Haemorrhoidal cushions contain blood vessels, connective tissue, and smooth muscle.
• Increased venous pressure causes dilation and congestion of these vascular cushions.
• Over time, connective tissue support weakens, leading to prolapse.
• Internal haemorrhoids originate from the superior haemorrhoidal plexus; external haemorrhoids arise from the inferior haemorrhoidal plexus.

Risk factors

• Chronic constipation or diarrhoea.
• Straining during defecation.
• Pregnancy and childbirth.
• Obesity.
• Prolonged sitting (e.g., office workers, drivers).
• Heavy lifting.

Signs and symptoms

• Painless rectal bleeding: bright red blood on toilet paper or in the toilet bowl.
• Anal discomfort or itching: more common with external haemorrhoids.
• Prolapse: internal haemorrhoids may protrude through the anus.
• Perianal swelling or lump: suggestive of thrombosed external haemorrhoids.
• Mucous discharge: in prolapsed haemorrhoids.

Investigations

• Clinical diagnosis: based on history and examination.
• Digital rectal examination (DRE): palpation of masses, ruling out other anorectal pathology.
• Proctoscopy: visualisation of internal haemorrhoids.
• Flexible sigmoidoscopy: if rectal bleeding is persistent or there are red flag symptoms (e.g., weight loss, anaemia).

Management

1. Conservative Management:

• Increase dietary fibre: 25–30g daily to soften stools (e.g., whole grains, fruits, vegetables).
• Hydration: encourage adequate fluid intake.
• Avoid straining: use of stool softeners if necessary.
• Sitz baths: warm water soaks for symptom relief.
• Topical treatments: hydrocortisone cream (for inflammation) or local anaesthetics (for pain relief).

2. Minimally Invasive Procedures:

• Rubber band ligation: first line for symptomatic internal haemorrhoids.
• Sclerotherapy: injection of an irritant solution to shrink haemorrhoids.
• Infrared coagulation: used for smaller internal haemorrhoids.

3. Surgical Management:

• Haemorrhoidectomy: reserved for large, prolapsed, or refractory haemorrhoids.
• Stapled haemorrhoidopexy: alternative to excisional surgery, reducing post-op pain.
• Thrombosed haemorrhoids: if severe pain, may require surgical excision.