What are haemorrhoids?
- aka Piles
- Enlarged, prolpased anal vascular cushions
- They are classified according to their size
Describe the normal role of anal vascular cushions?
- Act to assist anal sphincter in maintaining continence
- There are three vascular cushions
- Positioned at 3-, 7- and 11-o’clock positions
- When enlarged they are known as haemorrhoids
What is the prevalence peak of haemorrhoids?
45-65 years
Describe the different classifications of haemorrhoids?
- 1st degree:
- Bleed, do not prolapse
- 2nd degree:
- Prolapse during defecation but reduce spontaneously
- 3rd degree:
- Prolapse during defecation but can be digitally reduced
- 4th degree:
- Irreducibly prolapsed
What are the main risk factors for haemorrhoids?
- Excessive straining / constipation
- Increasing age
- Raised intra-abdominal pressure
- pregnancy, chronic cough, ascites
What are the common clinical features of haemorrhoids?
- Painless bright red rectal bleeding
- Commonly after defaecation, on paper or pan
- *Blood is on the surface of stool, not mixed in
- Bleeding and prolapse are the cardinal features
Differentials for haemorrhoids?
- Exclude other causes of rectal bleeding:
- Malignancy
- Inflammatory bowel disease
- Diverticular disease
- Anal fissure
- Anal fistula
- Perianal abscess
Investigations that should be performed in someone with suspected haemorrhoids?
- Proctoscopy to confirm diagnosis
- Prolonged bleeding may should warrant FBC and coagulation screen
- Flexible sigmoidoscopy or colonscopy to exclude malignancy in certain cases
Complications of haemorrhoids?
- Thrombosis
- Can cause secondary gangrene
- Ulceration
- Skin tags
- Perianal sepsis
Describe the management of haemorrhoids?
- Mostly conservative
- Increase fibre and fluid intake
- Laxative
- Topical lignocaine gel
- Non-surgical treatment
- Surgical treatment
Describe the non-surgical interventions for haemorrhoids?
- Symptomatic 1st and 2nd degree haemorrhoids
- Rubber-band ligation (RBL)
- Haemorrhoid drawn out with suction gun then rubber band placed on its neck
- Infrared coagulation
- Photocoagulation
- Rubber-band ligation (RBL)
What are the main complications of RBL?
- Recurrence, pain and bleeding
- If band is placed below the dentate line
Describe the surgical management of haemorrhoids?
- Haemorrhoidectomy
- Stapled or Milligan Morgan
What are the main complications of a haemorrhoidectomy?
- Bleeding
- Infection
- Constipation
- Faecal incontinence
Describe the pathogenesis of haemorrhoids?
- Degeneration of supporting fibroelastic tissue and smooth muscle
- With protrusion at the 3, 7 and 11 o’clock positions
- Prolapse of columnar epithelial component at later stages
Waht positions will haemorrhoids be visible during proctoscope?
- Right anterior
- Right posterior
- Left lateral
