Haemorrhoids

Haemorrhoids, also known as piles, are swollen, enlarged veins that develop inside or outside the anus and rectum. They are a common condition resulting from the abnormal swelling or displacement of normal anatomical structures in the anal canal called anal cushions. These cushions are made of blood vessels, smooth muscle, and connective tissue. Haemorrhoids are classified into two main types: internal and external. Internal haemorrhoids originate above the dentate line, are covered by columnar epithelium, and are typically painless, often presenting with bleeding or prolapse. External haemorrhoids originate below the dentate line, are covered by anoderm, and can be painful, especially if a blood clot forms within them (thrombosed). Mixed haemorrhoids have components of both types. The exact cause is multifactorial, primarily involving the deterioration and downward displacement of the supportive tissues of the anal cushions, often contributed to by increased pressure in the abdomen.

Symptoms

Painless, bright red rectal bleeding during or after a bowel movement (blood on toilet paper, in the toilet bowl, or on the surface of the stool)
Anal itching (pruritus ani)
Anal discomfort or aching
Sensation of a lump or fullness at the anus, especially after a bowel movement
Mucous discharge
Faecal soiling (less common)
Sensation of incomplete evacuation (less common)
Severe or constant anal pain (may indicate a thrombosed external haemorrhoid or a strangulated internal haemorrhoid, which are emergency symptoms)
Large volume of rectal bleeding, especially if associated with dizziness, lightheadedness, or fainting (emergency symptom)
Change in bowel habit (new onset constipation or diarrhoea, change in stool calibre, emergency symptom)
Dark, tarry stools (melena) or blood mixed with stool (suggests bleeding from higher up in the gastrointestinal tract, emergency symptom)
Abdominal pain, fever, or weight loss (emergency symptom)
A prolapsed haemorrhoid that cannot be pushed back in and is causing severe pain (strangulation, emergency symptom)

Causes & Risk Factors

Deterioration of the supportive connective tissues (Trebitz's muscle and Parks' ligament) within the anal cushions, leading to their downward displacement or prolapse and venous distension
Increased intra-abdominal pressure from factors such as straining during bowel movements, pregnancy, or chronic coughing, which contributes to vascular engorgement and stretching of supportive structures
Straining during bowel movements
Prolonged sitting on the toilet
Chronic constipation or diarrhoea
Low-fibre diet
Obesity (elevated body mass index)
Heavy lifting
Increasing age (weakening of supporting tissues)
Pregnancy (due to hormonal changes and increased intra-abdominal pressure)
Family history
Erect posture (humans are uniquely susceptible)

Diagnosis

Detailed medical history focusing on symptoms like bleeding, prolapse, pain, itching, discharge, bowel habits, diet, fluid intake, and toilet habits
Personal and family history of colorectal cancer or inflammatory bowel disease
Visual inspection of the perianal region to identify external haemorrhoids, skin tags, fissures, or other lesions
Digital Rectal Examination (DRE) to assess anal sphincter tone, detect masses, and evaluate for tenderness (uncomplicated internal haemorrhoids are usually not palpable)
Anoscopy, which is essential for visualizing internal haemorrhoids, determining their location, and assessing their grade, especially for patients with rectal bleeding
Flexible Sigmoidoscopy or Colonoscopy, indicated to rule out other causes of rectal bleeding (e.g., polyps, colorectal cancer) for patients over 40-50 years old, or any patient with risk factors for colorectal cancer or atypical symptoms
Complete Blood Count (CBC) to assess for anaemia in cases of chronic or significant bleeding
Diagnosis is primarily clinical, based on history and physical examination including anoscopy

Treatment Options

Increase dietary fibre intake to 25-35 grams per day through diet and/or supplements (e.g., psyllium, methylcellulose) to soften stool and reduce straining
Increase water intake (e.g., 1.5-2 litres per day)
Avoid prolonged sitting on the toilet, avoid straining, and respond to the urge to defecate promptly
Sitz baths (warm water baths for 10-15 minutes, 2-3 times per day) to soothe symptoms
Topical agents like creams, ointments, or suppositories containing local anaesthetics (e.g., lidocaine), corticosteroids (e.g., hydrocortisone), or astringents (e.g., witch hazel) for short-term symptomatic relief
Oral phlebotonics (venoactive agents) like flavonoids (e.g., diosmin/hesperidin) which may improve venous tone and reduce bleeding and swelling
Rubber Band Ligation (RBL), where an elastic band is placed at the base of the internal haemorrhoid to cut off blood supply, causing it to fall off (most common office-based procedure for Grade I-III)
Sclerotherapy, involving injection of a chemical solution into the haemorrhoid to shrink it
Infrared Coagulation (IRC), using infrared radiation to coagulate vessels supplying the haemorrhoid, causing it to shrink
Haemorrhoidectomy, surgical excision of haemorrhoids, which is highly effective but associated with significant post-operative pain and longer recovery (for refractory Grade III, Grade IV, or large symptomatic external tags)
Stapled Haemorrhoidopexy (PPH), using a circular stapling device to remove tissue above haemorrhoids, pulling them into position and reducing blood flow (less painful than excisional haemorrhoidectomy but higher recurrence)
Doppler-Guided Haemorrhoidal Artery Ligation (HALO), where arteries supplying haemorrhoids are identified and ligated with sutures, often combined with recto-anal repair (RAR)
For thrombosed external haemorrhoids presenting within 72 hours, elliptical excision under local anaesthesia can provide immediate relief; otherwise, conservative management is preferred
Strangulated or acutely thrombosed internal haemorrhoids require urgent surgical consultation and may involve hospitalization and urgent haemorrhoidectomy
During pregnancy, management is typically conservative (diet, fluids, topical agents) as haemorrhoids often improve after delivery; surgical intervention is generally avoided unless severe complications arise

Frequently Asked Questions

Do haemorrhoids increase my risk of getting colon cancer?

No, haemorrhoids are a benign condition and do not increase your risk of developing colon cancer.

Is bleeding from the rectum always caused by haemorrhoids?

No, rectal bleeding is not always caused by haemorrhoids. Other conditions such as anal fissures, colorectal polyps, colorectal cancer, or inflammatory bowel disease can also cause rectal bleeding. It is important to see a doctor to determine the cause of any rectal bleeding.

How much fibre should I eat per day to prevent haemorrhoids?

To help prevent haemorrhoids, it is recommended to increase your dietary fibre intake to 25-35 grams per day through foods like fruits, vegetables, and whole grains, or through fibre supplements.

Are over-the-counter creams effective, and how long should I use them?

Over-the-counter creams, ointments, or suppositories containing local anaesthetics or corticosteroids can provide short-term symptomatic relief. However, evidence for their long-term effectiveness is weak, and they are generally recommended for short-term use only.

When should I see a doctor for my haemorrhoids?

You should see a doctor if you experience severe or constant anal pain, a large volume of rectal bleeding (especially with dizziness or fainting), a change in bowel habits, dark or tarry stools, abdominal pain, fever, weight loss, or a prolapsed haemorrhoid that cannot be pushed back in and is causing severe pain.

What is the difference between internal and external haemorrhoids?

Internal haemorrhoids form inside the rectum, above the dentate line, and are typically painless, often presenting with bleeding or prolapse. External haemorrhoids form outside the anus, below the dentate line, and can be painful, especially if a blood clot forms within them (thrombosed).

Is surgery the only permanent solution?

Surgery, particularly excisional haemorrhoidectomy, has the highest success rate and lowest recurrence rate for haemorrhoids. However, many patients with Grade I and II haemorrhoids can achieve long-term symptom control with conservative management or office-based procedures like rubber band ligation. Recurrence is possible even after surgery if lifestyle modifications are not maintained.

What is rubber band ligation and is it painful?

Rubber band ligation (RBL) is a common office-based procedure where a small elastic band is placed at the base of an internal haemorrhoid, cutting off its blood supply. The haemorrhoid and band typically fall off within 5-10 days. The dossier does not explicitly state the level of pain, but it is a widely used and effective procedure.

How long is the recovery time after haemorrhoid surgery?

Recovery time after haemorrhoid surgery, especially excisional haemorrhoidectomy, can involve significant post-operative pain and a longer recovery period. The exact duration can vary depending on the type of surgery and individual factors, and the dossier does not specify a precise timeline.

Can haemorrhoids go away on their own?

Haemorrhoid symptoms can be intermittent, with flare-ups followed by periods of remission. For pregnant women, haemorrhoids often resolve or improve significantly after delivery. While symptoms may improve, underlying factors often need to be addressed through lifestyle changes or medical intervention to prevent recurrence or worsening.

Why are haemorrhoids so common during pregnancy?

Haemorrhoids are very common during pregnancy, especially in the third trimester and postpartum period, due to hormonal changes that affect veins and increased intra-abdominal pressure.

Are there any risks to my baby if I have haemorrhoids during pregnancy?

The provided information does not indicate any direct risks to the baby if you have haemorrhoids during pregnancy.

What treatments are safe to use for haemorrhoids while pregnant or breastfeeding?

During pregnancy, management is typically conservative, focusing on diet, increased fluids, and topical agents. Surgical intervention is generally avoided unless there are severe complications like refractory thrombosis or strangulation. These conservative measures are also generally safe while breastfeeding.

Can exercise make my haemorrhoids worse?

Regular physical activity is generally recommended as it helps prevent constipation and promotes regular bowel function, which can help prevent haemorrhoids. The dossier does not suggest that exercise makes haemorrhoids worse.

What is a thrombosed haemorrhoid?

A thrombosed haemorrhoid is one where a blood clot forms within the haemorrhoid, usually an external one. This typically causes acute, severe pain.

Does straining to urinate affect haemorrhoids?

The dossier primarily links straining during bowel movements and increased intra-abdominal pressure to haemorrhoids. While straining to urinate could potentially increase intra-abdominal pressure, the dossier does not explicitly state a direct link to affecting haemorrhoids.

Can I get anaemia from bleeding haemorrhoids?

Yes, chronic or significant bleeding from haemorrhoids can lead to iron deficiency anaemia.

What is the difference between a haemorrhoid and an anal fissure?

Haemorrhoids are swollen veins, while an anal fissure is a small tear in the lining of the anal canal. Both can cause anal discomfort and bleeding, but they are distinct conditions.

Will I need a colonoscopy to diagnose my haemorrhoids?

A colonoscopy is not required for all patients to diagnose haemorrhoids. It is typically indicated to rule out other, more serious causes of rectal bleeding, such as polyps or colorectal cancer, especially for patients over 40-50 years old or those with risk factors or atypical symptoms.

How can I tell if my symptoms are from haemorrhoids or something more serious?

While haemorrhoids are common, symptoms like severe pain, large volume bleeding, dark or tarry stools, changes in bowel habits, abdominal pain, fever, or weight loss could indicate a more serious condition. It is important to consult a doctor for an accurate diagnosis.

Is there a link between inflammatory bowel disease (IBD) and haemorrhoids?

Inflammatory bowel disease (IBD) is listed as a differential diagnosis for symptoms that might be mistaken for haemorrhoids, meaning they can present similarly. However, the dossier does not state a direct link or increased risk of developing haemorrhoids due to IBD.

Can certain foods trigger a haemorrhoid flare-up?

A low-fibre diet is identified as a risk factor for haemorrhoids, as it can lead to constipation and straining. While specific trigger foods are not listed, maintaining a high-fibre diet is recommended for prevention and management.