Haemorrhoids (Piles)

Haemorrhoids are enlarged vascular cushions in the anal canal.¹ They originate either above the dentate line (internal) or below the dentate line (external). It is thought that as the overlying mucosa and skin becomes redundant, especially with straining and constipation, it prolapses into the anal canal. A small amount of prolapse results in bleeding or thrombosis but the patient becomes aware when the prolapse is extensive.

Internal haemorrhoids

• Are covered by mucosa and do not have sensory innervations.
• Internal haemorrhoids are classified according to the degree of prolapse, although this may not always reflect the severity of symptoms:^1,2
  • First degree haemorrhoids: bleed but do not prolapse
  • Second degree haemorrhoids: prolapse but reduce spontaneously
  • Third degree haemorrhoids: prolapse but can be reduced manually
  • Fourth degree haemorrhoids: permanently prolapsed and cannot be reduced

External haemorrhoids

• Are covered by squamous epithelium and have sensory innervation.
• External haemorrhoids lie under the perianal skin just inside and outside the anal verge below the dentate line.
• They may be visible on external examination.

• Common but estimates of prevalence vary widely, as many people do not consult their doctor and many other anorectal symptoms are misdiagnosed as piles.
• Probably affect about 50% of the population over the age of 50 years.
• Nearly half the population will experience at least one haemorrhoidal episode at some point during their lives.
• Prevalence generally increases with age.

Risk factors

Proposed factors include constipation, diarrhoea, prolonged straining, increased abdominal pressure such as ascites or pregnancy, childbirth, heavy lifting, chronic cough, anal intercourse and hereditary factors.

• Symptoms depend on the severity or degree of the haemorrhoid.
  • First-degree: painless rectal bleeding
  • Second-degree: mild discomfort, bleeding
  • Third-degree: pain, bleeding, mucus discharge
  • Fourth-degree: pain, bleeding, possible thrombosis, and strangulation
• Bleeding often occurs with defecation, and is bright red. It can vary from streaks on the toilet paper to blood dripping into the toilet. Blood may be seen on the outside of the stool but is not mixed in with the stool.
• Anal itching and irritation may result from chronic mucus discharge irritating the perianal skin.
• A sense of rectal fullness or discomfort may result when prolapse occurs with bowel movement.
• Pain is rarely experienced, unless the haemorrhoid prolapses into the anal canal and becomes swollen, incarcerated, and thrombosed (perianal haematoma).
• Soiling may occur with third- or fourth-degree haemorrhoids as a result of impaired continence or mucus discharge.
• External haemorrhoids do not usually cause symptoms unless thrombosis occurs, in which case they may cause acute severe pain.
• The pain of a thrombosed haemorrhoid usually peaks 48-72 hours after onset, and is self-limited to 7-10 days.
• Bleeding may occur if the clot erodes through the skin. This may be infrequent and is often evident on underwear.

Signs

• The perineum may appear normal if there is a non-prolapsed internal haemorrhoid. These haemorrhoids are also difficult to feel on digital rectal examination.
• The perineum may be macerated from chronic mucus discharge causing local irritation.
• Proctoscopy may reveal tissue with evidence of chronic venous dilatation, friability, mobility, and squamous metaplasia.
• Bluish, soft bulging vessels covered by mucosa may be seen on examination if internal haemorrhoids have prolapsed.
• With external haemorrhoids, bluish, soft bulging vessels covered by skin may be seen.

• Colorectal cancer: early diagnosis essential; refer to NICE Guidelines for early diagnosis of malignancy³
• Inflammatory bowel disease: Crohn's, ulcerative colitis
• Rectal prolapse
• Adenomatous polyps, anal fissure, Condylomata acuminata (genital warts), perianal abscess, anal fistula
• Other causes of pruritus ani, e.g. threadworms, contact dermatitis

• Proctoscopy should be performed to confirm or refute the diagnosis of haemorrhoids, unless there is isolated rectal bleeding in small amounts in an otherwise fit young person only associated with straining at stool or significant constipation, or a previous diagnosis of haemorrhoids with no new symptoms.
• Full blood count: anaemia, infection.

• Urgent referral is recommended for: profuse bleeding, severely painful thrombosed haemorrhoids, possibility of malignancy.³
• Routine referral is recommended for: persistent bleeding, severe prolapse, haemorrhoids affecting daily living.
• Diagnostic uncertainty.
• People with internal haemorrhoids that have prolapsed and become swollen, incarcerated, and thrombosed, should be referred for haemorrhoidectomy.
• People with first or second degree haemorrhoids who do not respond to conservative treatment should be referred for non-operative techniques (e.g. rubber band ligation, sclerotherapy, or infra-red photocoagulation) or surgery (haemorrhoidectomy).

Treatment depends on the degree of prolapse and severity of symptoms.

• Internal haemorrhoids:
  • First- or second-degree haemorrhoids can usually be treated conservatively as long as symptoms are minor.
  • If symptoms are severe, especially bleeding or pain then referral is required.
  • Third- and fourth-degree haemorrhoids usually require surgery.
• External haemorrhoids:
  • If diagnosed within 72 hours of onset of pain, severely painful thrombosed external haemorrhoids are best managed by urgent referral and excision under local anaesthetic.⁴
  • Incision and drainage of clot relieves pain but the thrombosis often recurs and there may be persistent bleeding.
  • Thrombosed haemorrhoids presenting more than 72 hours after the onset of pain are usually treated conservatively. Analgesia, bed rest, and cold compresses or warm baths may help relieve symptoms in people who have mild to moderate discomfort with symptoms that do not warrant referral.

Non-surgical

• Prevention and management of constipation: soften stool and avoid constipation: increasing fluid and fibre intake.
• Avoiding straining.
• Losing weight and increasing exercise contribute to a healthier bowel habit, but there is no evidence that they relieve the symptoms of haemorrhoids.
• Good perianal hygiene may be helpful in providing symptomatic relief and preventing perineal dermatitis.
• Symptomatic relief with topical therapies:
  • Many people report some benefit, especially local anaesthetics and topical corticosteroids.
  • Bland, soothing (astringent) preparations may help to relieve local irritation.
  • Anaesthetic preparations may alleviate pain, burning, and itching. They should be used for only a few days as they may cause sensitisation of the anal skin.
  • Topical corticosteroids may reduce inflammation and pain. Local infection must be excluded before use and should only be used for up to 7 days as prolonged use may lead to skin atrophy, contact dermatitis and skin sensitisation.
  • Sitting in warm-water baths are often recommended and have a soothing effect.

Surgical

• External haemorrhoidal excision for thrombosed external haemorrhoids. Patient require oral analgesics to control pain for the first few days after the procedure.
• Rubber band ligation:
  • Rubber band ligation is the best outpatient treatment for haemorrhoids. Up to 80% of patients are satisfied with the short term outcome.¹
  • Indicated for internal haemorrhoidal bleeding or prolapse.
  • 15-20% recurrence rate of internal haemorrhoids within 5 years.
• Other outpatient procedures include such as sclerotherapy, photocoagulation and cryotherapy.⁴
• Haemorrhoidectomy:
  • Surgery is reserved for large symptomatic haemorrhoids that do not respond to outpatient treatment. Haemorrhoidectomy is performed under general anaesthesia.
  • It is required when clots repeatedly form in external haemorrhoids, ligation fails to treat internal haemorrhoids, the protruding haemorrhoid cannot be reduced, or there is persistent bleeding.⁵
  • Several operative techniques have been described, e.g. Milligan-Morgan's open haemorrhoidectomy.
  • Excisional haemorrhoidectomy is more effective long term than the less invasive technique of rubber band ligation, at least for grade III haemorrhoids, but at the expense of increased pain, higher complications and more time off work.⁶
• Stapling procedure:
  • The circular stapled technique offers a significantly less painful alternative to Milligan-Morgan haemorrhoidectomy and is associated with an earlier return to normal activity.⁷
  • Stapled haemorrhoidectomy may cause a full thickness excision of the rectal wall and injuries to the anal sphincter. It does not allow for the treatment of concomitant anal disease.⁵
  • The stapling procedure is not effective for treating large external haemorrhoids.⁴
• Doppler guided haemorrhoidal artery ligation and stapled haemorrhoidopexy are new alternatives to the traditional and more painful open or closed haemorrhoidectomy.¹

• Ulceration may result from the thrombosis of external haemorrhoids.
• Skin tags may result from repeated episodes of dilatation and thrombosis causing enlargement of the overlying skin.
• Ischaemia, thrombosis, or gangrene may develop from internal haemorrhoids that remain prolapsed.
• Perianal sepsis may occur but is rare.
• Severe or persistent bleeding may lead to anaemia.

• Episodes tend to worsen with time, but only about 10% of people needing surgery to alleviate symptoms.
• Thrombosed external haemorrhoids: if not treated in 2-4 weeks the clot in the thrombosed vessels will either drain spontaneously or be gradually reabsorbed. The discomfort will therefore gradually resolve.
• Haemorrhoids in pregnancy usually resolve after delivery.

• Avoidance of constipation with a high fibre, high fluid diet
• Avoidance of straining