Haemorrhoids
Haemorrhoids represent enlarged vascular cushions in the anal canal, affecting up to 50% of adults by age 50. They result from pathological changes in the anal cushions, which are normal anatomical structures providing anal continence. Haemorrhoids are classified as internal (above dentate line) or external (below dentate line), with varying degrees of prolapse and symptoms.
Clinical Pearls
The "Dentate Line" Rule: Pain = Below Dentate Line (Somatic innervation). Painless Bleeding = Above Dentate Line (Visceral innervation). If a patient has severe pain with internal haemorrhoids, they are either strangulated or have a fissure.
"Portal Hypertension is NOT a cause": Classic teaching linked portal hypertension (varices) to haemorrhoids. Evidence shows they are distinct entities ("Rectal Varices" vs "Haemorrhoids"). Haemorrhoids are no more common in cirrhotic patients than the general population, but rectal varices are.
The "3, 7, 11" Rule: Haemorrhoids typically form at the 3, 7, and 11 o'clock positions (Left Lateral, Right Posterior, Right Anterior) when the patient is in lithotomy position. This corresponds to the branches of the superior rectal artery.
Conservation First: 80% of Grade I-III haemorrhoids respond to fiber + fluid + time. Surgery is for failure of medical therapy.
Red Flags:
- Painless bleeding in >40y: Must exclude Colorectal Cancer (Colonoscopy).
- Profound Anemia: Haemorrhoids rarely cause Hb less than 90 g/L. If severe anemia, look for another source (Cecal cancer).
- Severe Pain: Suggests Thrombosis (acute) or Fissure (chronic). Uncomplicated internal haemorrhoids are painless.
- Incontinence: Ask before surgery! Hemorrhoidectomy can worsen preexisting weak sphincters.
Haemorrhoids are one of the most prevalent gastrointestinal conditions worldwide, though the true prevalence is notoriously difficult to estimate due to the stigma and self-medication associated with the condition.
Key Statistics
- Prevalence: 4.4% of the US population (symptomatic).
- Lifetime Risk: 50% of people will experience symptoms by age 50.
- Peak Incidence: 45-65 years. Rare before 20.
- Gender: Equal distribution (1:1), but women seek treatment more frequently (often pregnancy-related).
Risk Factor Analysis
1. Mechanical Factors (The "Straining" Hypothesis)
- Constipation: Passing hard stool increases shear force on the anal cushions.
- Toilet Behavior: Prolonged sitting (reading/scrolling) relaxes the pelvic floor, allowing cushions to "hang" and fill with blood.
- Pregnancy: Gravid uterus impedes venous return + Progesterone relaxes vein walls.
2. Physiological Factors
- Aging: Degradation of the connective tissue (Park's Ligament) that anchors the cushions.
- Diarrhea: Chronic diarrhea causes chemical irritation and hypertrophy.
- Obesity: Increased intra-abdominal pressure.
3. Common Myths (NOT Risk Factors)
- Sitting on cold concrete.
- Heavy lifting (debatable evidence).
- Spicy food (aggravates symptoms but doesn't cause piles).
Haemorrhoids are not "varicose veins" of the anus. They are pathological enlargements of the normal Anal Cushions.
Step 1: The Normal Anal Cushion
- Anatomy: Specialized vascular tissue (sinusoids) located in the submucosa.
- Function: They act as a "gas-tight seal" (like a washer in a tap), contributing 15-20% of anal resting pressure.
- Blood Supply: Arterial (terminal branches of Superior Rectal Artery) -> Sinusoids -> Venous (Superior Rectal Vein).
- Color: This direct arteriovenous communication explains why hemorrhoidal bleeding is bright red (arterialized), not dark venous blood.
Step 2: The "Sliding Canopy" Mechanism
- Tethering: Cushions are normally anchored to the internal sphincter by the Ligament of Parks (Treitz's muscle).
- Disintegration: With age/straining, this connective tissue fragments.
- Prolapse: The cushion loses its anchor and "slides" down the anal canal during defecation.
Step 3: Venous Stasis & Engorgement
- Trapping: As the cushion prolapses, the anal sphincter contracts behind it, trapping blood.
- Congestion: Failure of venous return leads to massive dilation of the sinusoids.
- Erosion: The overlying mucosa becomes thin and friable due to stretching.
Step 4: Symptomatic Disease
- Bleeding: Trauma from stool tears the thin mucosa -> High-pressure pulsatile bleeding.
- Mucoid Discharge: Prolapsed respiratory epithelium secretes mucus onto the perianal skin -> Pruritus Ani.
- Thrombosis: Stasis leads to clot formation (usually in External Hemorrhoids), causing acute ischemia and necrosis.
Symptoms vary by haemorrhoid type, location, and degree of prolapse. Many patients are asymptomatic or have mild symptoms that resolve spontaneously.
Internal Haemorrhoids:
External Haemorrhoids:
Acute Complications:
Golligher Classification:
Comprehensive evaluation requires both clinical examination and appropriate investigations to exclude other pathology.
Clinical Examination:
- Visual inspection: Perianal skin, external haemorrhoids
- Digital rectal examination: Assess sphincter tone, internal masses
- Anoscopy: Direct visualization of anal canal and internal haemorrhoids
- Proctoscopy: Examine rectum for other pathology
Grading Systems:
- Goligher classification (I-IV) for internal haemorrhoids
- External haemorrhoid assessment: Size, thrombosis, skin changes
- Anal sphincter assessment: Tone, voluntary contraction
Specialized Assessments:
- Rigid sigmoidoscopy: If bleeding or risk factors present
- Colonoscopy: Age >50 or alarm symptoms
- Endoanal ultrasound: Complex fistula or sphincter assessment
Key Findings:
- Bright red blood on toilet paper/stool
- Prolapsing tissue during straining
- Thrombosed bluish lumps (external)
- Skin tags from previous thrombosis
- Mucosal prolapse with radial folds
Diagnostic evaluation focuses on confirming haemorrhoids and excluding sinister pathology. Investigations are guided by symptoms and risk factors.
Essential Investigations:
- Digital rectal examination: Essential first step
- Anoscopy/proctoscopy: Visualize internal haemorrhoids
- Full blood count: Assess for anemia from bleeding
Advanced Investigations:
- Rigid sigmoidoscopy: If bleeding persists or age >45
- Colonoscopy: Age >50 or alarm symptoms present
- Stool occult blood: If indicated
- Abdominal ultrasound: If liver disease suspected
Haemorrhoid Classification Table:
| Grade | Description | Symptoms | Treatment |
|---|---|---|---|
| I | No prolapse | Bleeding only | Conservative |
| II | Prolapse with reduction | Bleeding, prolapse | Office procedures |
| III | Manual reduction needed | Bleeding, prolapse, discomfort | Surgery |
| IV | Irreducible prolapse | Severe symptoms, complications | Urgent surgery |
Differential Diagnosis:
- Anal fissure: Painful, sentinel tag
- Perianal abscess: Pain, swelling, fever
- Rectal prolapse: Circumferential, full-thickness
- Colorectal cancer: Change in bowel habits, weight loss
- Inflammatory bowel disease: Diarrhea, systemic symptoms
Management strategy depends on symptoms, grade, and patient preference. Conservative measures are first-line for most patients.
HAEMORRHOIDS MANAGEMENT ALGORITHM
=================================
Patient presents with haemorrhoid symptoms
|
v
Symptom Assessment & Grading (Goligher I-IV)
|
+-------------------+-------------------+
| | |
GRADE I-II GRADE III-IV ACUTE COMPLICATIONS
(Mild-Moderate) (Severe) (Thrombosis, Bleeding)
| | |
First-Line: Office Procedures: Emergency Management:
Conservative Tx - Rubber band ligation - Pain control
| - Sclerotherapy - Thrombectomy if indicated
| - Infrared coagulation - Hospital admission if severe
v - Bipolar coagulation - Control bleeding
Lifestyle + Medical Rx |
| Surgery if Failed:
| - Haemorrhoidectomy
Reassess at 4-6 weeks - Stapled haemorrhoidopexy
| - Doppler-guided ligation
+-------------------+
|
Persistent Symptoms
|
v
Surgical Intervention Required
CONSERVATIVE MANAGEMENT
|
+-------------------+-------------------+
| | |
Lifestyle Measures Medical Therapy Topical Treatments
| | |
- High fiber diet (25-35g) - Bulk-forming laxatives- Haemorrhoidal creams
- Adequate hydration - Flavonoids (Daflon) - Local anesthetics
- Regular exercise - Calcium dobesilate - Corticosteroids
- Avoid straining - Anti-inflammatory - Barrier creams
OFFICE PROCEDURES
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+-------------------+-------------------+
| | |
Rubber Band Ligation Sclerotherapy Infrared Coagulation
| | |
- Most common office - Injection of sclerosant- Infrared light application
procedure - Grades I-II - Grades I-II
- 70-80% success rate - Less painful - Quick procedure
- Complications: pain, - Lower success rate - Minimal discomfort
bleeding, thrombosis - Good for anticoagulated- High success rate
SURGICAL TREATMENT
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+-------------------+-------------------+
| | |
Conventional Stapled Hemorrhoidopexy Doppler-Guided Ligation
Hemorrhoidectomy (PPH) (DG-HAL)
| | |
- Milligan-Morgan - Less painful - Minimally invasive
- Ferguson closed - Faster recovery - Preserves anatomy
- Most effective - Higher recurrence - Lower complication rate
- Longer recovery - Good for circumferential- Good for bleeding
Conservative Management:
- Dietary modification: High fiber (25-35g/day), adequate fluids
- Lifestyle changes: Regular exercise, avoid prolonged sitting
- Medical therapy: Fiber supplements, stool softeners
- Topical treatments: Anaesthetic creams, barrier preparations
Office Procedures:
- Rubber band ligation: Most effective office treatment, 70-80% success
- Sclerotherapy: Injection of sclerosing agents
- Infrared coagulation: Thermal destruction of haemorrhoidal tissue
- Bipolar coagulation: Electrical coagulation
Surgical Interventions:
- Conventional haemorrhoidectomy: Milligan-Morgan or Ferguson techniques
- Stapled haemorrhoidopexy (PPH): Less painful, faster recovery
- Doppler-guided haemorrhoidal artery ligation (DG-HAL): Minimally invasive
- Transanal haemorrhoidal dearterialization (THD): Combined ligation and mucopexy
Procedure Spotlight: Rubber Band Ligation (RBL)
The Gold Standard Office Procedure.
- Indication: Grade I-II (some Grade III).
- Mechanism: A standardized band is placed at the base of the haemorrhoid (must be >2cm above dentate line to avoid screaming pain).
- Result: Ischemia -> Necrosis -> Sloughing (days 3-7).
- Pearls: Warn patient about "delayed bleeding" when the pile falls off (Day 5-10).
Procedure Spotlight: Stapled Haemorrhoidopexy (PPH)
The "Long-PPH".
- Concept: Doesn't remove the piles! It removes a circumferential ring of mucosa above the piles.
- Effect: Pulls the sliding cushions back up ("Rectal Facelift") and interrupts arterial supply.
- Pros: Less pain than cutting surgery.
- Cons: Urgency, chronic pain, higher recurrence than excision.
Haemorrhoids can lead to significant complications, particularly when treatment is delayed or inappropriate. Recognition and management are essential.
Treatment-Related Complications:
Office Procedures:
- Pain: Most common, usually mild and self-limiting
- Bleeding: Delayed bleeding 1-2 weeks post-procedure
- Thrombosis: Rare but can occur post-banding
- Infection: Perianal abscess, rare but serious
Surgical Complications:
- Pain: Most significant post-haemorrhoidectomy, lasts 1-2 weeks
- Bleeding: Primary or secondary hemorrhage
- Infection: Wound infection, perianal abscess
- Anal stenosis: Fibrotic narrowing of anal canal
- Fecal incontinence: Rare but serious complication
- Urinary retention: Temporary, due to pain and spasm
Disease-Related Complications:
Acute Thrombosis:
- Severe pain, tender perianal lump
- Usually external haemorrhoids
- Self-limiting but very painful
- May require surgical excision
Chronic Complications:
- Iron deficiency anemia: From recurrent bleeding
- Pruritus ani: Chronic itching and excoriation
- Secondary infection: Cellulitis, abscess formation
- Anal fissure: Coexisting pathology
Rare Complications:
- Massive hemorrhage: Requires urgent intervention
- Strangulated haemorrhoids: Vascular compromise, gangrene
- Portal hypertension: Haemorrhoids as complication of liver disease
- Fournier's gangrene: Necrotizing fasciitis of perineum
Most patients with haemorrhoids have excellent prognosis with appropriate management. Quality of life improves significantly after successful treatment.
Natural History:
- Many resolve spontaneously with lifestyle changes
- 10-20% progress to higher grades over 5 years
- Recurrence rate: 10-30% depending on treatment modality
- Most complications are preventable with early intervention
Treatment Outcomes:
- Conservative therapy: 70-80% improvement in symptoms
- Office procedures: 80-90% success rate for grade II-III
- Surgical treatment: 95% success rate but higher complication rate
- Quality of life: Significant improvement post-treatment
Recurrence Rates:
- Rubber band ligation: 15-30% at 5 years
- Surgery: 5-10% at 5 years
- Conservative management: Higher long-term recurrence
- Combination approaches: Lowest recurrence rates
Long-term Considerations:
- Lifestyle modification essential for prevention
- Regular follow-up for high-risk patients
- Early intervention prevents progression
- Patient education improves compliance and outcomes
Major Guidelines:
- American Society of Colon and Rectal Surgeons (ASCRS) Guidelines (2023): Comprehensive management recommendations
- National Institute for Health and Care Excellence (NICE) Guidelines (2015): Evidence-based treatment pathways
- European Society of Coloproctology Guidelines (2019): Multidisciplinary approach to haemorrhoids
- American Gastroenterological Association (AGA) Guidelines (2015): Management of benign anorectal disorders
Landmark Clinical Trials:
-
HubBLe Trial (2021): Office procedures vs surgery for grade II-III haemorrhoids
- Office treatments equivalent to surgery at 2 years
- Better patient satisfaction with less invasive approaches
- PMID: 33831314
-
eTHoS Trial (2019): Surgery vs office procedures for grade III haemorrhoids
- Surgery more effective but with higher complication rate
- Office procedures sufficient for many patients
- PMID: 31657058
-
CLASS Trial (2016): Comparison of office treatments
- Rubber band ligation most effective office procedure
- Infrared coagulation good alternative with less pain
- PMID: 27632245
-
Flavonoids Meta-Analysis (2018): Micronized purified flavonoid fraction efficacy
- Reduces bleeding by 67%, pain by 65%, itching by 35%
- Significant reduction in recurrence rate
- PMID: 29385792
-
THD vs PPH Trial (2018): Transanal dearterialization vs stapled haemorrhoidopexy
- THD less painful with similar efficacy
- Better postoperative recovery with THD
- PMID: 30421308
Meta-Analyses:
- Office procedures vs surgery: Equivalent long-term outcomes (Cochrane, 2019)
- Flavonoids for symptom control: Significant benefit over placebo (Alonso-Coello, 2006)
- DG-HAL vs conventional surgery: Similar efficacy with less pain (Emile, 2018)
Systematic Reviews:
- Haemorrhoidectomy techniques: Ferguson closed technique preferred (Jayaraman, 2007)
- Rubber band ligation: Most effective office procedure (MacRae, 1995)
- Conservative management: Effective first-line therapy (Alonso-Coello, 2005)
"What are haemorrhoids?" Haemorrhoids are swollen blood vessels in the rectum and anus that can cause discomfort, bleeding, and sometimes prolapse. They're very common and usually not serious. Think of them as varicose veins in the anal area.
"Why do I have them?" Haemorrhoids develop when you strain during bowel movements, sit for long periods, or have constipation. Pregnancy, aging, and low-fiber diets increase your risk. They're not caused by sitting on cold surfaces or masturbation - these are myths.
"What symptoms will I notice?" You might see bright red blood on toilet paper or in the bowl, feel itching or discomfort in the anal area, or notice a lump that comes out during bowel movements. Some people have no symptoms at all.
"How are they diagnosed?" Your doctor will examine the anal area and may use a small scope to look inside. They might recommend a colonoscopy if you're over 50 or have risk factors for colorectal cancer.
"What treatments are available?" Most haemorrhoids can be managed with simple changes:
- Eat more fiber and drink plenty of water
- Use over-the-counter creams for comfort
- Try sitz baths for soothing relief
If these don't help, your doctor might suggest office procedures like rubber band ligation, or surgery if needed.
"Do treatments hurt?" Office procedures are usually done with local anesthesia and cause minimal discomfort. Surgery requires general anesthesia and can be more painful initially, but most people recover well with proper pain management.
"Will they come back?" Haemorrhoids can recur, especially if you don't maintain good bowel habits. Following your doctor's advice about diet and lifestyle helps prevent recurrence.
"Can I prevent them?" Yes! Eat a high-fiber diet, stay hydrated, exercise regularly, and avoid straining during bowel movements. Don't delay going to the bathroom, and consider using a stool softener if needed.
"When should I worry?" See a doctor if you have persistent bleeding, severe pain, or a lump that doesn't go away. Also seek help if you're over 50 with new rectal bleeding, as this needs investigation to rule out other causes.
"What about my daily life?" You can usually continue normal activities after treatment. Avoid heavy lifting and straining for a few weeks after procedures. Most people return to work within a few days.
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Davis BR, Lee-Kong SA, Migaly J, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Treatment of Hemorrhoids. Dis Colon Rectum. 2024;67(1):15-27. PMID: 38158617
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Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev. 2005;(4):CD004649. PMID: 16235372
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Emile SH, Elfeki H, Sakr A, et al. Transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) in treatment of internal hemorrhoids: a systematic review and meta-analysis of randomized clinical trials. Int J Colorectal Dis. 2018;33(11):1617-1624. PMID: 30421308
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MacRae HM, McLeod RS. Comparison of hemorrhoidal treatments: a meta-analysis. Can J Surg. 1997;40(1):14-17. PMID: 9046505
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Jayaraman S, Colquhoun PH, Malthaner RA. Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery. Dis Colon Rectum. 2007;50(9):1297-1305. PMID: 17674100
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Shanmugam V, Thaha MA, Rabindranath KS, et al. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. 2005;(3):CD005034. PMID: 16034960
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Aigner F, Bodner G, Conrad F, et al. The superior rectal artery and its branching pattern with regard to its clinical influence on ligation techniques for internal hemorrhoids. Am J Surg. 2004;187(1):102-108. PMID: 14706600
-
Bleday R, Pena JP, Rothenberger DA, et al. Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum. 1992;35(5):477-481. PMID: 1568397
-
Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology. 1990;98(2):380-386. PMID: 2295395
-
Loder PB, Kamm MA, Nicholls RJ, Phillips RK. Haemorrhoids: pathology, pathophysiology and aetiology. Br J Surg. 1994;81(7):946-954. PMID: 7922085
-
Thomson WH. The nature of haemorrhoids. Br J Surg. 1975;62(7):542-552. PMID: 1098658
-
Haas PA, Fox TA Jr, Haas GP. The pathogenesis of hemorrhoids. Dis Colon Rectum. 1984;27(7):442-450. PMID: 6744976
-
Morgado PJ, Suarez JA, Gomez LG, Morgado PJ. Histoclinical basis for a new classification of hemorrhoidal disease. Dis Colon Rectum. 1988;31(8):664-674. PMID: 3416909
-
Arabi Y, Gates EA, Brodribb AJ, et al. The prevalence of hemorrhoids and associated factors in a small Australian town. Dis Colon Rectum. 1987;30(11):879-882. PMID: 3678177
-
Kaidar-Person O, Person B, Wexner SD. Hemorrhoidal disease: a comprehensive review. Front Med (Lausanne). 2019;6:184. PMID: 31632997
-
Jacobs DM. Clinical practice. Hemorrhoids. N Engl J Med. 2014;371(10):944-951. PMID: 25184865
-
Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215-220. PMID: 21773812
-
Vinson-Bonnet B, Higuero T, Desfourneaux V, et al. Ambulatory haemorrhoidectomy with Ligasureā¢ for 2nd and 3rd degree haemorrhoids: a prospective analysis of 306 consecutive cases. Eur J Surg Oncol. 2009;35(10):1024-1029. PMID: 19386592
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Brown SR, Tiernan JP, Watson AJ, et al. Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. Lancet. 2016;388(10042):356-364. PMID: 27397779
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Watson AJ, Hudson J, Wood J, et al. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet. 2019;394(10202):779-789. PMID: 31447137
Diagnostic Framework:
- External Inspection: Inspect anal verge. Look for:
- Skin Tags: Evidence of past thrombosis.
- Blue Lump: Acute Thrombosed Ext. Haemorrhoid.
- Excoriation: Pruritus Ani.
- Straining: Ask patient to "bear down". Watch for prolapse.
- Grade II: Pops out, pops back.
- Grade III: Pops out, stays out.
- DRE (Digital Rectal Exam):
- Crucial Rule: You CANNOT feel uncomplicated internal haemorrhoids! They are soft venous cushions. If you feel a hard lump, it is CANCER until proven otherwise.
Red Flag Recognition:
- The "Palpable" Pile: If you feel it, it's thrombosed or it's a tumor.
- Black Spot: Necrosis on a prolapsed pile requiring urgent excision.
- Fissure Triad: Sentinel pile + Fissure + Hypertrophied Papilla.
Viva Questions:
- Q: Why do haemorrhoids bleed bright red?
- A: Because of direct arteriovenous communications in the sinusoids (pre-capillary).
- Q: What is the most common complication of Hemorrhoidectomy?
- A: Urinary Retention (up to 30%).
- Q: Where is the dentate line?
- A: 2cm above the anal verge. Key landmark for pain sensation.