Piles (Haemorrhoids): Diagnosis, Grading & Grade-Based Treatment

Definition & Anatomy

Classification: Internal vs. External

Grading (Goligher Classification — Internal Haemorrhoids)

"Mixed" haemorrhoids — Grade IV lesions with a significant cutaneous (external) component — represent external extensions from repeated congestion and oedema.

Clinical photograph: Grade III–IV prolapsing haemorrhoids (at rest vs. during Valsalva)

Diagnosis

History

• Bleeding: Bright red, painless, separate from stool — seen on paper or as a "fresh splash" in the pan
• Prolapse: Lump at the anal orifice during or after defecation
• Pruritus: Due to mucus discharge from prolapsed mucosa
• Pain: Unusual with internal haemorrhoids; pain suggests fissure, thrombosis, or another diagnosis
• Mucus discharge, perianal moisture, soiling

Examination

1. Inspection: Perianal skin, prolapsing tissue, skin tags
2. Digital rectal examination: Internal haemorrhoids are not palpable unless thrombosed
3. Anoscopy (proctoscopy): Definitive — visualises degree of protrusion, position, bleeding points. Use bevelled or slotted anoscope
4. Sigmoidoscopy / colonoscopy: Mandatory to exclude colorectal malignancy before attributing rectal bleeding to haemorrhoids, especially in patients >40 years or with risk factors

Important: Many patients attributing symptoms to "haemorrhoids" have another diagnosis (fissure, pruritus ani, warts, malignancy). Haemorrhoids coexist with other anal pathology.

Grade-Based Treatment

All Grades: Conservative (First-Line)

• Adequate dietary fibre: 20–30 g/day
• Fluid intake: 6–8 glasses of non-caffeinated, non-alcoholic beverages daily
• Defecatory habit modification: Avoid straining, prolonged toilet sitting
• Stool softeners: Docusate sodium, polyethylene glycol 3350
• Bulking agents: Psyllium/ispaghula
• Sitz baths: Warm water soaks, especially post-defecation
• Topical agents: Phenylephrine/petrolatum creams — temporarily relieve pain and itching; glucocorticoid creams with caution (risk of candidiasis)
• Phlebotonics (plant flavonoids/diosmin): Improve venous tone, stabilise capillary permeability; useful in Grades II–III; excellent safety profile

Grade I: Conservative → Sclerotherapy

• Submucosal injection of 5% phenol in arachis/almond oil, 3–5 mL per haemorrhoid
• Injected at the apex of the pedicle (not into the haemorrhoid itself)
• Causes fibrosis obliterating vascular channels + mucosal support scar
• Repeat at 8 weeks if needed
• Largely superseded by rubber band ligation at many centres due to risk of deep injection complications (prostatitis, pelvic sepsis)

Grade II: Rubber Band Ligation (RBL) ± Sclerotherapy

• Tight elastic bands applied to the base of each haemorrhoidal pedicle, above the dentate line
• Causes ischaemic necrosis → haemorrhoid sloughs in ~10 days
• The resulting fibrosis supports residual anal cushions
• All three primary haemorrhoids may be banded at one session, or one per visit
• Patient warned of post-procedure bleeding when tissue sloughs
• Reassess at 4–6 weeks; repeat if needed

Grade III: RBL → HAL / Stapled Haemorrhoidopexy → Haemorrhoidectomy

1. Rubber Band Ligation: First-line procedure; may need multiple sessions
2. Haemorrhoidal Artery Ligation (HAL / HALO):
   • Doppler-guided ligation of haemorrhoidal arteries
   • Can treat Grade II–III; lower recurrence than RBL (HubBLe trial), but less cost-effective
   • Better postoperative pain scores than conventional surgery
3. Stapled Haemorrhoidopexy (PPH — Procedure for Prolapse and Haemorrhoids):
   • Circular stapler removes a strip of mucosa/submucosa above the haemorrhoids, retracting prolapsed cushions
   • Suitable for Grade II–III
   • Less postoperative pain but higher recurrence rate than formal haemorrhoidectomy
4. Formal Haemorrhoidectomy: If the above fail (see Grade IV below)

Grade IV: Haemorrhoidectomy (Surgical Excision)

• Grade III–IV haemorrhoids (main indication)
• Grade II that failed all non-operative treatments
• "Mixed" haemorrhoids with a well-defined external component
• Bleeding severe enough to cause anaemia

• Open technique (Milligan-Morgan): Haemorrhoidal pedicles ligated and excised leaving wounds open to granulate
• Closed technique (Ferguson): Wounds sutured closed after excision
• LigaSure / electrothermal: Bipolar vessel-sealing devices used as alternatives

External Haemorrhoids / Thrombosed External Haemorrhoid (Perianal Haematoma)

• Presents as sudden-onset painful, olive-shaped blue subcutaneous swelling at the anal margin
• Caused by straining, coughing, or heavy lifting
• If presenting within 48 hours: Evacuation of clot under local anaesthesia
• If presenting later: Conservative management — analgesia, warm baths, laxatives; most resolve in 3–4 days by fibrosing or spontaneous extrusion

Complications of Haemorrhoids

Grade-Based Treatment Summary