Haemorrhoids

• A haemorrhoid is an enlargement of the vascularity of the anal cushions in the anal canal. As a result, the anal cushions increase in size and can project distally, both within the anal canal and externally.
• • First degree: anal cushions bleed but remain in the rectum (no prolapse)
  • Second degree: prolapse of haemorrhoids on defaecation or straining (spontaneously reduces)
  • Third degree:  prolapse of haemorrhoids on defaecation or straining (requires manual reduction)
  • Fourth degree: prolapse remains at all times and is irreducible
• Risk factors for haemorrhoids include:

  • Constipation: this will predispose the patient to increase time straining on the toilet
  • Increased age
  • Increased abdominal pressure, such as in pregnancy and labour
  • Diarrhoea
  • High BMI
• Typical symptoms of haemorrhoids may include

  • Pruritis ani (itching peri-anally)
  • Rectal bleeding: this is usually bright red, fresh blood seen on the tissue paper upon wiping (not mixed in with stool)
  • Palpable lump in or around the anus: this may or may not be reducible
  • Pain: most haemorrhoids are painless; however, they become acutely tender and painful if the haemorrhoid thromboses
  • Discomfort around the anus, fullness or feeling of incomplete defaecation (known as tenesmus)
• Relevant bedside investigations in the context of haemorrhoids include:

  • rigid Proctoscopy: to visualise the anal canal (or anoscopy, rectoscope)
  • If unable to do in primary care may need a referral
• Relevant laboratory investigations in the context of haemorrhoids include:

  • Full blood count (FBC): to identify anaemia (a red flag for malignancy)
  • Faecal immunochemical test (FIT): a stool sample usually performed in the community if there is suspicion of colorectal cancer
• A diagnosis of haemorrhoids can be reached with a history and typical examination findings. Usually, imaging is not required.
• A thrombosed hemorrhoid occurs when a blood clot forms inside a hemorrhoidal vein, obstructing blood flow and causing a painful swelling of the anal tissues. Thrombosed hemorrhoids are not dangerous, but they can be very painful and cause rectal bleeding if they become ulcerated.
• Acutely thrombosed haemorrhoids can present acutely with pain and tenderness. Initial management includes:

  • Analgesia
  • Laxatives (to reduce straining)
  • Sitz hot salt bath: this is a shallow bath to sit in to relieve discomfort in the perineal region
• Conservative management:

  • Increase fibre and fluids to avoid constipation
  • Regular laxative use
  • Avoid medications that cause constipation such as opioids
  • Topical local anaesthetic gels if discomfort occurs
• Rubber band ligation is a common outpatient non-surgical treatment for haemorrhoids.

  A suction gun draws up the haemorrhoid, followed by a firing of a rubber band to cut off the blood supply to the haemorrhoid 
• Surgical management:

  • Trans-anal haemorrhoid de-arterialisation - tie off the artery feeding into the anal cushion
  • Haemorrhoidectomy - excision of the prolapsed haemorrhoids and/or anal cushions
• Haemorrhoids are usually located in the 3, 7 and 11 o'clock position when viewed with the patient in the supine lithotomy position
• Thrombosed haemorrhoids:

  • Oedematous
  • Congested/purple
  • Acutely painful
  • Tight spasms of the anal sphincter makes DRE extremely painful
• Strangulated haemorrhoids:

  • Very painful
  • May become necrotic or ulcerated
  • Symptomatic relief - bed rest, ice packs, topical anaesthetics
  • Some may have urgent haemorrhoidectomy for thrombosed or strangulated haemorrhoids
  • Need prophylactic antibiotics after operation
• Internal haemorrhoids = above the dentate line

  External haemorrhoids = below dentate line
• •Mucosa below the dentate line is highly innervated so external haemorrhoids are often itchy and painful

  •Above the dentate line not well innervated with pain fibres so internal haemorrhoids are usually painless (unless strangulated)
• Management:

  •Basic treatment:

  •lifestyle measures- increase water intake, healthy high fibre diet

  •Avoid straining

  •Laxatives if required

  •Analgesia (Avoid constipating medications eg opiates)

  •Topical agents: OTC usually contain combination of lubricant and/or astringent (draws water out of tissue causing shrinkage) and/or topical anaesthetics and/or steroids

  •Referral (urgency depending on severity):

  •Persistent symptoms despite non-surgical management

  •4th degree haemorrhoid or Large 3rd degree

  •Symptomatic thrombosed/strangulated haemorrhoid
• •For internal haemorrhoids many treatments can be in outpatients with minimal anaesthetic due to them being above dentate line and less innervated; external haemorrhoids often need surgical inpatient management due to being highly innervated and more sensitive to treatments