Haemorrhoids

Definition/diagnostic criteria

Haemorrhoids, commonly known as piles, are symptomatic vascular cushions located in the anal canal. They are classified based on their location relative to the dentate line: internal haemorrhoids occur above the line, while external haemorrhoids are located below it. Internal haemorrhoids are further graded: Grade I do not prolapse, Grade II prolapse but reduce spontaneously, Grade III prolapse and require manual reduction, and Grade IV are irreducible and may become strangulated or thrombosed.

Epidemiology
Haemorrhoids are a common condition, affecting approximately 40% of the UK population at some stage in their lives, with the prevalence increasing with age. Haemorrhoids are particularly common among individuals aged 45-65 years. Risk factors include chronic constipation, straining during defecation, prolonged sitting, pregnancy, obesity, and a low-fibre diet.

Diagnosis

Clinical features
Patients with haemorrhoids typically present with painless rectal bleeding, often bright red and noted during or after defecation. Itching, discomfort, and the sensation of incomplete evacuation may accompany internal haemorrhoids. Prolapsed haemorrhoids may cause pain, particularly if they become thrombosed. External haemorrhoids may present with acute pain due to thrombosis or irritation.

Investigations
Diagnosis is primarily clinical. Visual inspection, digital rectal examination (DRE), and anoscopy are standard first-line investigations. Anoscopy allows for direct visualisation of internal haemorrhoids, assisting with grading. External haemorrhoids can be assessed through inspection and palpation.

Further investigations are warranted if there is a suspicion of other anorectal pathology or if “red flag” symptoms are present, such as unexplained weight loss, changes in bowel habits, or anaemia. In such cases, flexible sigmoidoscopy or colonoscopy may be necessary to rule out malignancy or inflammatory bowel disease. Full blood count (FBC) can be useful to assess for anaemia in patients reporting significant or chronic rectal bleeding.

Treatment

Conservative management
First-line treatment involves dietary and lifestyle modifications aimed at reducing constipation and straining. Increased fibre intake along with adequate fluid intake is recommended. Bulk-forming laxatives, such as ispaghula husk, are commonly prescribed.

Topical therapies
Over-the-counter topical treatments, such as creams or suppositories containing corticosteroids or local anaesthetics, are used to relieve symptoms of pain and itching. However, these should be used short-term to avoid mucosal atrophy.

Non-surgical procedures
Rubber band ligation is considered the most effective office-based treatment for Grade II and III haemorrhoids. This involves placing a rubber band around the base of the haemorrhoid, cutting off its blood supply, causing it to necrose and slough off. Sclerotherapy, in which a sclerosing agent is injected into the haemorrhoid, is another option for Grade I and II haemorrhoids, though it is less commonly used in the UK.

Surgical management
Haemorrhoidectomy, the surgical excision of haemorrhoids, is generally reserved for Grade IV haemorrhoids, or those that are severely symptomatic and refractory to non-surgical treatment. Stapled haemorrhoidopexy is another surgical option for prolapsing haemorrhoids, which may offer quicker recovery times compared to traditional haemorrhoidectomy.

Prognosis
The prognosis for haemorrhoids is generally good. Conservative management is effective in many cases, with symptomatic relief and resolution of bleeding in most patients. Recurrence rates can be high, especially for patients who do not adhere to lifestyle modifications or have ongoing risk factors. Rubber band ligation has a success rate of 70-80%, with recurrence being more common in patients with higher-grade haemorrhoids. Surgical treatment offers longer-lasting results, but carries risks of complications such as pain, infection, or incontinence.