Haemorrhoids are simply enlarged anal vascular cushions. It is associated with increased intra-abdominal pressure (straining, coughing, weightlifting), pregnancy, obesity, age.
When looking at a patient in the lithotomy position, we can identify 3 vascular cushions at the 3, 7 and 11 o’clock positions.
The vascular cushions become engorged and enlarged with haemorrhoids.
They most prevalent between ages 45-65 years old.
They can be classified according to their size:
Classification | Description |
1º | Remain in the rectum |
2º | Prolapse through the anus on defecation but can spontaneously reduce. |
3º | Prolapse through the anus on defecation but require digital reduction. |
4º | Remain persistently prolapsed. |
⚠️ Risk factors
- Straining (constipation)
- Age
- Intra-abdominal pressure
- Pregnancy
💭 Differentials
It is important to rule out other causes of rectal bleeding such as malignancy, IBD, diverticular disease.
Perianal differentials may include: anal fissures, perianal abscess, anal fistulas.
🔍 Investigations
🏆 Proctoscopy may be used to confirm diagnosis.
If the haemorrhoids are complicated, a colonoscopy may be advised to exclude any other pathologies before surgery.
On examination a prolapsed haemorrhoid may be seen. It is generally difficult to feel an internal haemorrhoid as they are compressible.
An FBC + clotting profile may be warranted with prolonged bleeding (to assess for any anaemia and any coagulatory issues).
🧰 Management
- 🥇Conservative management - lifestyle advice, increasing fibre intake, drinking adequate fluids, laxatives if necessary.
- Anusol - is a topical medication that shrinks haemorrhoids. It may also be given as a variant containing hydrocortisone which shouldn’t be given long term.
- Topical analgesia - for example lignocaine gel. Oral analgesia can compound the constipation and worsen symptoms so they are to be avoided.
- Rubber band ligation - for 1º and 2º haemorrhoids. This involves suctioning the haemorrhoids down with a gun and placing a rubber band over the neck to ligate it.
- Haemorrhoid artery ligation (HAL)/transanal haemorrhoid dearterialisation (THD) - for 2º and 3º haemorrhoids. The vessel is identified with Doppler and then is tied off.
- Haemorrhoidectomy - for 3º and 4º haemorrhoids. The haemorrhoidal tissue is excised and can either be left open or closed with a suture/staple which remains in-situ.
Complications of surgical intervention are: recurrence, anal strictures, faecal incontinence.
😷 Presentation
- ⭐️ Painless rectal bleeding of fresh blood - often seen when wiping or in the pan afterwards. It is not mixed in the stool.
- Pruritus/itchy anus
- Rectal fullness (feeling lump in/around anus)
