Throwback to colorectal clinic, when I was super excited at the prospect of seeing real haemorrhoids and the doctor just looked at me like I had been dropped too much as a kid.
Definition: a.k.a piles. Disrupted and dilated anal cushions, which are prone to protrusion, bleeding and prolapse into the anal canal.
The anus is lined mainly by discontinuous masses of spongy vascular tissue- the anal cushions- which contribute to anal closure.
Internal haemorrhoids = arise from superior haemorrhoidal plexus and lie above dentate line
External haemorrhoids = arise from inferior haemorrhoidal plexus, below dentate line
1st degree- remain in rectum
2nd degree- prolapse through the anus of defecation but spontaneously reduce
3rd degree- prolapse through the anus on defecation and require digital reduction
4th degree- remain persistently prolapsed
-constipation with prolonged straining is a key factor
-congestion from a pelvic tumour, pregnancy, congestive cardiac failure, or portal hypertension are important in only a minority of cases
Epidemiology: common, prevalence = 4-5%
Peak age = 45-65 years
-bright red rectal bleeding (bright red = blood from capillaries of underlying lamina propria)
-bleeding often coats stools, on the tissue, or dripping into the pan after defecation
-there may be mucous discharge and pruritus ani (itching)
-anal lumps or prolapsing tissue
As there are no sensory fibres above the dentate line (squamomucosal junction), piles are not painful unless they are external haemorrhoids, which thrombose when they protrude and are gripped by the anal sphincter, blocking venous return. These can cause severe pain.
-severe anaemia may occur = pallor
-abdominal exam to rule out other diseases
-PR exam: prolapsing haemorrhoids are obvious, internal haemorrhoids are not palpable
Proctoscopy- see the internal hemorrhoids (allows visual examination of anus and rectum)
Medical (for 1st degree)
–increase fluid and fibre intake
-topical analgesics (cream)
-topical steroids for short periods only
Non-operative (2nd and 3rd degree and 1st degree with failed medical therapy- may remove need for surgery)
–Rubber band ligation– banding produces an ulcer to anchor the mucosa as the bands are applied just proximal to the haemorrhoid incorporating tissue that falls away after 2-3 days. It has the lowest recurrence rate.
–Sclerosants- (for 1st or second degree), 2mL of 5% phenol in almond/ arachis oil is injected into the haemorrhoid above the dentate line, inducing inflammation and subsequent fibrosis resulting in mucosal fixation. Recurrence higher.
–Infra-red coagulation- applied to localised areas of haemorrhoids, works by coagulating vessels and tethering mucosa to subcutaneous tissue. As successful as banding and may be less painful.
–Cryotherapy-freezing, has a high complication rate and is not recommended.
Surgery- (symptomatic 3rd or 4th degree)
Excisional haemorrhoidectomy– most effective treatment = excision of haemorrhoids +/- ligation of vascular pedicles. Scalpel, electrocautery or laser may be used.
Day case surgery, about 2 weeks recovery.
Stapled haemorrhoidopexy/ haemorrhoidectomy– for prolapsing haemorrhoids
Involves mucosectomy 2cm proximal to the dentate line to ‘hitch up’ the prolapsing anal lining and disrupting proximal blood flow.
May result in less pain, shorter hospital stay, quicker recovery. Used when there is a large internal component, but higher recurrence and prolapse rate than excisional surgery.
Indications: symptomatic 3rd or 4th degree haemorrhoids
Complications: constipation, infection, anal stricture, bleeding, recurrence, incontinence (rare)
Prolapsed, thrombosed haemorrhoids:
-some advocate early surgery
-pain usually subsides after 2-3 weeks
-bleeding, prolapse, thrombosis of haemorrhoids
Complications of intervention:
Rubber band ligation- bleeding, infection, pain
Sclerosants- impotence, prostatitis, perineal sepsis, retroperitoneal sepsis, hepatic abscess
Surgery- constipation, infection, anal stricture, bleeding, recurrence, incontinence (rare)
Prognosis: often a chronic problem, with recurrence of symptoms necessitating repeat local treatments. Surgery can provide long-term relief for severe symptoms.