Hemorrhoids
DEFINITION AND ANATOMY
Haemorrhoids are symptomatic enlargement and distal displacement of normal anal vascular cushions. Internal haemorrhoids arise above the dentate line and are covered by columnar mucosa; external haemorrhoids arise below it and are covered by anoderm, with somatic innervation and greater pain sensitivity. Normal cushions contribute to fine continence.
CAUSES AND CLASSIFICATION
Predisposing factors include constipation, straining, prolonged toilet sitting, pregnancy, raised intra-abdominal pressure and age-related connective tissue weakening. Internal haemorrhoids are graded: I (bleed, no prolapse), II (prolapse but reduce spontaneously), III (require manual reduction), IV (irreducible/strangulated). External thrombosis presents as a painful bluish perianal lump.
CLINICAL FEATURES AND EXAMINATION
Painless bright-red bleeding during defecation is typical of internal haemorrhoids. Prolapse, mucus discharge, pruritus and soiling may occur. Pain suggests thrombosis, strangulation, fissure or abscess rather than uncomplicated internal haemorrhoids. External thrombosed haemorrhoids cause sudden severe pain and a tender lump. Examine perianal region, perform digital rectal examination and anoscopy when tolerated. Do not attribute rectal bleeding automatically to haemorrhoids, particularly with anaemia, weight loss, altered bowel habit or family history.
INVESTIGATIONS AND DIFFERENTIAL
Diagnosis is usually clinical with anoscopy. Flexible sigmoidoscopy or colonoscopy is indicated according to age, screening status, bleeding pattern and alarm features. Differential includes anal fissure, fistula, abscess, rectal prolapse, inflammatory bowel disease and colorectal cancer.
MANAGEMENT
First-line management is fibre, adequate fluids, stool softening, avoidance of straining and limiting time on the toilet. Topical preparations may relieve short-term symptoms but do not correct prolapse. Grade I–II and selected grade III internal haemorrhoids may be treated with rubber-band ligation; alternatives include injection sclerotherapy or infrared coagulation. Persistent grade III–IV or combined disease may require excisional haemorrhoidectomy, stapled haemorrhoidopexy in selected cases, or Doppler-guided haemorrhoidal artery ligation. Acute thrombosed external haemorrhoid may be treated conservatively or by excision in selected early severe cases.
COMPLICATIONS
Complications include recurrent bleeding and iron-deficiency anaemia, thrombosis, strangulation, ulceration, mucosal discharge and postoperative pain, urinary retention, bleeding, stenosis or rarely incontinence.