Haemorrhoids

Gastroenterology (12%) Core Clinical Conditions

1A: Able to diagnose and manage

Jump to content

Definition Aetiology Pathophysiology Risk factor Sign and Symptoms Investigations Management

Haemorrhoids, also known as piles, are a common condition that affects many individuals in varying degrees of discomfort. These swollen blood vessels in the lower rectum and anus can cause significant pain, itching, and discomfort.

• Increased pressure in the veins surrounding the anus and rectum. This increased pressure is often a result of prolonged sitting or standing, obesity, chronic constipation, or straining during bowel movements. The pressure leads to the swelling of blood vessels in the rectal area, resulting in haemorrhoids.

• Weakening of the connective tissues and muscles that support the veins in the rectal area.

• Ageing, pregnancy, and childbirth are common factors that contribute to this weakening.

• Dietary factors also play a role in the development of haemorrhoids. A low-fibre diet can lead to constipation, which in turn puts additional strain on the rectal area during bowel movements.

• Straining causes increased pressure on the blood vessels, leading to haemorrhoids.

• A sedentary lifestyle, lack of exercise, and prolonged sitting or standing can increase the pressure on the anal area, making individuals more susceptible to haemorrhoids.

• Genetic and hereditary factors that can increase an individual's susceptibility.

• A family history of haemorrhoids can predispose someone to develop the condition. .

1. Increased pressure: Piles typically occur due to increased pressure on the veins in the rectal and anal region. This increased pressure can be caused by a variety of factors, such as chronic constipation, prolonged straining during bowel movements, prolonged sitting or standing, obesity, or pregnancy. The increased pressure compromises the blood flow and leads to the swelling and enlargement of the blood vessels.
2. Weakening of connective tissues: Another contributing factor to the development of piles is the weakening of the connective tissues supporting the blood vessels in the anal region. Connective tissues, including the muscles and elastic fibres, help maintain the integrity and strength of the blood vessels. But with increased pressure and repeated straining, these tissues can become stretched and weakened, making the blood vessels more susceptible to distention and swelling.
3. Impaired blood circulation: Increased pressure and weakened connective tissues impair the blood circulation in the veins around the anus. This impaired circulation increases the risk of blood pooling in the vessels, leading to congestion and the formation of haemorrhoids. The inadequate blood flow also compromises the delivery of oxygen and nutrients to the tissues, further exacerbating their swelling.
4. Inflammation and engorgement: Piles are often characterized by inflammation and engorgement of the affected blood vessels. In response to the increased pressure, the body's immune system triggers an inflammatory response, causing the blood vessels to become swollen, red, and painful. This inflammatory process can be further intensified by irritation of the rectal and anal tissues due to friction, excessive wiping, or exposure to harsh chemicals.
5. Thrombosis: In some cases, piles can lead to the formation of blood clots within the swollen veins. This condition, known as thrombosed haemorrhoids, can result in severe pain and discomfort. The presence of a blood clot further obstructs blood flow, exacerbates inflammation, and adds to the severity of symptoms.

1. Sedentary Lifestyle:
Leading a sedentary lifestyle is considered one of the primary risk factors for developing piles. Prolonged periods of sitting or standing without movement can put excessive pressure on the veins in the rectal area, leading to swelling and inflammation. This is particularly true for individuals who have desk jobs or engage in activities that involve long hours of sitting.
2. Chronic Constipation:
Frequent episodes of constipation can significantly increase the risk of piles. Straining during bowel movements exerts pressure on the rectal veins, leading to their inflammation and subsequent development of haemorrhoids. Insufficient fibre intake, low fluid consumption, and a lack of physical activity can contribute to chronic constipation, exacerbating the risk of piles.
3. Pregnancy:
Pregnancy poses a higher risk of developing piles due to various factors. The growing uterus puts additional pressure on the veins in the pelvic area, hindering the smooth flow of blood and leading to swollen haemorrhoidal veins. Hormonal changes during pregnancy can also weaken the veins, making pregnant women more susceptible to developing piles. Thankfully, piles experienced during pregnancy usually resolve after childbirth.
4. Obesity:
Obesity is recognized as a risk factor for numerous health conditions, and piles are no exception. Excess body weight puts undue pressure on the pelvic veins, causing them to stretch and enlarge. Additionally, obesity often coincides with a sedentary lifestyle and poor dietary habits, further increasing the likelihood of developing piles.
5. Age:
While piles can affect individuals of any age, the risk factor tends to increase with age. As we grow older, the tissues supporting the veins in the rectal area become weaker and more susceptible to damage. Moreover, individuals who lead a sedentary lifestyle or suffer from chronic health conditions associated with old age are at an increased risk of developing piles.

1. Rectal Bleeding: One of the most common signs of piles is rectal bleeding. Bright red blood may be noticed on toilet paper, in the toilet bowl, or on stool. This bleeding occurs when the swollen blood vessels are irritated during bowel movements.
2. Pain and Discomfort: Piles can cause pain and discomfort, especially during bowel movements. Individuals with piles may experience itching, burning, or aching sensations around the anus. The pain can range from mild to severe, depending on the severity of the condition.
3. Swelling and Lump: Piles can cause a noticeable swelling around the anus. This swelling may be accompanied by a small lump or multiple lumps that can be felt near the anus. The size and appearance of the lump(s) can vary from person to person.
4. Mucus Discharge: Some individuals with piles may experience mucus discharge from the anus. This discharge can be observed on toilet paper or on underwear and is often accompanied by itching and irritation.
5. Incomplete Bowel Movements: Piles can sometimes interfere with the normal passage of stool, leading to a feeling of incomplete bowel movements. This sensation occurs due to the presence of swollen blood vessels that obstruct the passage of stool.
6. Difficulty Sitting: Piles can make sitting uncomfortable, especially for long periods. The pain and pressure in the rectal area may intensify when sitting, making it difficult to find a comfortable position.
7. Protrusion of haemorrhoids: In more severe cases, piles may become swollen to the point that they protrude outside the anus. These protruding haemorrhoids can be pushed back inside, but they often require medical attention for proper treatment.

Physical examination: by taking a detailed history. Enquiring about the duration and frequency of symptoms, any aggravating or relieving factors, and the impact on the patient's daily life. Following the history, a physical examination is conducted. This examination involves inspecting the anus and rectum for any external or internal piles. Additionally, a digital rectal examination (DRE) may be performed to assess the rectal tone and any associated abnormalities.

Sigmoidoscopy or colonoscopy: to visualise the rectum and lower gastrointestinal tract.

• Lifestyle modifications such as increasing dietary fibre intake, promoting regular exercise, and maintaining good bowel habits.

• Topical treatments, such as ointments or creams, may be prescribed to manage symptoms like itching and pain.

• Surgical procedures such as rubber band ligation, sclerotherapy, or haemorrhoidectomy may be recommended for patients who continue to experience significant discomfort or complications from piles.

Jump to other topics below: