Makindo Medical Notes

💉 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

• NICE – BNF: Haemorrhoids

🌟 Teaching pearl: Bright red, painless bleeding is classically internal haemorrhoids. Always exclude malignancy in rectal bleeding, especially in older patients.