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|Haemorrhoids (Piles)
💉 Key sign: Bright red blood on stool, toilet paper, or dripping into the bowl. Pain may occur if thrombosed or prolapsed.
📖 About
- Haemorrhoids are vascular cushions at the anus, not simply varicosities.
- Located at the 3, 7, and 11 o’clock positions (lithotomy view).
- Help maintain continence, but when enlarged → symptomatic haemorrhoids.
- Affect ~10% of the population, peak between ages 45–65.
⚠️ Aetiology / Risk Factors
- Chronic constipation, straining, low-fibre diet.
- Increased intra-abdominal pressure: pregnancy, ascites, chronic cough.
- Internal haemorrhoids: arise above dentate line, usually painless (unless strangulated).
- External haemorrhoids: arise below dentate line, often itchy or painful.
🩺 Clinical Features
- Anal discomfort, sensation of “something there.”
- Bleeding: bright red, usually on wiping rather than mixed with stool.
- Thrombosed or prolapsed piles → severe pain.
- Rectal fullness, pruritus, occasional continence issues.
- May require proctoscopy for diagnosis (not always palpable).
📊 Classification
- 1️⃣ First degree: Remain in rectum, not visible.
- 2️⃣ Second degree: Prolapse with defaecation, reduce spontaneously.
- 3️⃣ Third degree: Prolapse, require manual reduction.
- 4️⃣ Fourth degree: Persistently prolapsed, irreducible.
🔍 Investigations
- FBC, U&E, CRP to exclude other pathology (anaemia from haemorrhoids is rare).
- Proctoscopy for direct visualisation.
⚠️ Complications
- Thrombosis, ulceration, gangrene, perianal infection.
🔄 Differentials
- Perianal streptococcal infection, herpes simplex, perianal candidiasis.
- Always consider colorectal malignancy in persistent rectal bleeding.
💊 Management
- 🎯 Conservative: Hydration, high-fibre diet, bulk laxatives, topical agents (e.g. Anusol suppositories/creams after defaecation, morning & night).
- Local topical preparations may combine anaesthetics, corticosteroids, astringents, lubricants, and antiseptics.
- ⛑️ Thrombosed piles: bed rest, analgesia, ice packs. May resolve or leave skin tags. Consider emergency haemorrhoidectomy in severe cases.
- 🩹 Procedures:
- Rubber band ligation – for 1st/2nd degree haemorrhoids.
- Injection sclerotherapy (phenol in oil) – for 1st/2nd degree.
- HALO (haemorrhoidal artery ligation operation) – less invasive option.
- Haemorrhoidectomy – if refractory to first-line measures.
📚 References
🌟 Teaching pearl: Bright red, painless bleeding is classically internal haemorrhoids. Always exclude malignancy in rectal bleeding, especially in older patients.
Clinical Cases
- 🩸 Case 1 – Age 28: Presented with painless bright-red rectal bleeding noted on toilet paper after defecation. Examination revealed small, non-thrombosed internal haemorrhoids (grade I). Managed conservatively with high-fibre diet, hydration, and topical hydrocortisone.
- 💢 Case 2 – Age 46: Complained of prolapsing anal lumps and discomfort after straining. Found to have grade III mixed haemorrhoids requiring rubber band ligation. Education given on bowel habits and avoidance of prolonged sitting.
- 🚑 Case 3 – Age 62: Presented acutely with severe anal pain and a tender bluish perianal swelling. Diagnosed with thrombosed external haemorrhoid. Treated with analgesia, topical lidocaine, and sitz baths; surgical excision discussed if pain persisted.
