Haemorrhoid

Haemorrhoids, also called piles, are swollen or inflamed “cushions” of veins in the anal canal. Haemorrhoids are normal anatomical structures which are involved in maintaining continence, but the term is usually used to refer to cases where they cause symptoms. They may be classified as internal (above the dentate line), external (below the dentate line), or mixed.

Etiology

Haemorrhoids are usually the result of increased intraabdominal pressure, due to chronic constipation, heavy lifting, extended periods of sitting, pregnancy, etc. This leads to higher hydrostatic pressure in the haemorrhoids, causing the swelling which make them clinically manifest.

Cirrhosis may cause anorectal varices which may present similarly to haemorrhoids.

Classification of internal haemorrhoids

Stage	Description
I	Haemorrhoid does not prolapse out of the anus
II	Haemorrhoid prolapses when straining, but spontaneously reduce at rest
III	Haemorrhoid prolapses when straining, but is manually reducible
IV	Haemorrhoid is irreducible

Clinical features

Haemorrhoids cause painless fresh bleeding at the end of defecation and may cause mucous discharge. If they are internal and prolapse or they are external, a palpable anal mass is present. They are usually painless but may be painful.

Haemorrhoids may thrombose, causing acute pain or subacute pain (which occurs over multiple days). They may also incarcerate, causing acute intolerable pain.

Diagnosis and evaluation

The diagnosis of haemorrhoids is clinical. However, it’s important to exclude malignancy, IBD, and rectal prolapse as causes of the symptoms before proceeding to treatment.

Treatment

Generally, stage I and II internal haemorrhoids and all external haemorrhoids are treated conservatively while stage III and IV are treated surgically.

Conservative therapy involves lifestyle changes to decrease the hydrostatic pressure, like increasing fluid intake and fibre intake. Time on the toilet should also be reduced. Local ointments or suppositories containing a corticosteroid and a local anaesthetic may also be used.

Surgery

There are multiple options for outpatient surgical treatment. A Barron ligature is the most effective procedure, and involves placing a rubber ring around the haemorrhoid, causing fibrosis and reduction in size. Other options include sclerotherapy or photocoagulation.

There are also multiple options for inpatient surgical treatment, most being a form of submucosal total excision (haemorrhoidectomy). This procedure may be performed with a scalpel or with more advanced tools like staples, electrocautery, or ultrasonic excision. Haemorrhoidal artery ligation with recto-anal repair (HAL-RAR) is a new and minimally invasive technique, where the haemorrhoidal artery is ligated, and the prolapsed haemorrhoidal tissue is stapled or sutured to the mucosa.