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Haemorrhoids

1. Definition

2.Grading

• Haemorrhoids are graded into four degrees
  • 1^st degree - symptomatic but do not prolapse
    

  • 2^nd degree - prolapse with defaecation but reduce spontaneously
  • 3^rd degree - Prolapse and require manual reduction
    

  • 4^th degree - Irreducible - click here to see a picture of 4th degree thrombosed haemorrhoids

3. Epidemiology

• Estimate of prevalence vary widely
• Common condition
• Prevalence increases with age
• Nearly half the population will experience one haemorrhoidal episode at some point during their lives

4. Aetiology

• Age
• May be an element of hereditary disposition
• Constipation
• Prolonged straining
• Increased abdominal pressure
  • pregnancy
  • ascites
  • childbirth
  • heavy lifting
  • chronic cough

5. Symptoms

• Mostly haemorrhoids are completely aysmptomatic and therefore no treatment is required

• Other symptoms include
  • painless PR bleeding on the toilet paper
  • Anal itching
  • Mucous discharge
  • Prolapse - described as the feeling of something "coming down"
  • Discomfort + pain
  • Soiling
  • Acute thrombosis + strangulation - severe pain that usually peaks at 48-72 hours after onset + lasts 7-10 days
  • Symptoms of anaemia if enough blood is lost
  
• Symptoms depend on the severity/degree of the haemorrhoids
  • 1^st degree - painless PR bleeding on the toilet paper
  • 2^nd degree - mild discomfort + bleeding
  • 3^rd degree - mucous discharge, pain, bleeding
  • 4^th degree - pain, bleeding, strangulation, thrombosis

6. Diagnosis

• History and Examination
• Proctoscopic inspection of anal canal
• Beware! - in those with symptoms not typical of haemorrhoids + PR bleeding over 50 - this requires further bowel investigation for malignancy and IBD.

7. Management 

• Asymptomatic haemorrhoids do not require treatment

• 1^st degree or 2^nd degree haemorrhoids - as long as symptoms as minor, non-surgical management can be followed. If symptoms are severe then rubber band ligation can be performed

• 3^rd and 4^th degree haemorrhoids - usually require surgery

7.1 Conservative Management

• Avoidance of straining

• Prevention and management of constipation - dietary advice, bulking agents, increase fibre intake

• Good perianal hygiene

• Warm baths - soothing effect

• Anaesthetic creams

7.2 Surgical Management

7.2.1 Rubber Band Ligation

• Rubber Band ligation
  • For internal Grade 1 to 2 haemorrhoids

  • 30% chance of recurrence

7.2.2 Haemorrhoidectomy

• Recurrent thrombosed external haemorrhoids
• Failed attempts at rubber band ligation
• Irreducible haemorrhoids
• Persistent bleeding

• Significantly less painful
• Quicker return to normal activity

• May lead to full thickness excision of rectal wall + surrounding structures
• Anal sphincter damage
• Not effective for large external haemorrhoids

8. Further Reading