Complete Medical Treatment Plan for Piles (Haemorrhoids)

Definition & Classification

• Internal haemorrhoids — arise above the dentate line, covered by columnar/transitional mucosa; typically painless
• External haemorrhoids — below the dentate line, covered by squamous epithelium; painful (especially when thrombosed)

Step 1 — Conservative (Medical) Management

A. Dietary & Lifestyle Modification

• Dietary fibre: 20–30 g/day (reduces bleeding by ~53% in RCTs). Patients should keep a diet diary and supplement if needed
• Fluid intake: 6–8 glasses of non-alcoholic, non-caffeinated beverages daily
• Avoid straining and prolonged time on the toilet
• Weight management and physical activity

B. Pharmacological Agents

Step 2 — Office-Based Procedural Therapy

A. Rubber Band Ligation (RBL) ⭐ Most Common

• Grades: II and III (Grade I may also benefit with proximal band placement)
• Technique: Slotted anoscope → band placed just proximal to the internal haemorrhoid above the dentate line (never distal — causes severe pain)
• Mechanism: Creates ischaemic necrosis; tissue sloughs in 5–7 days
• Success rate: 65–75%
• Sessions: 1 band per visit (up to 3 sessions, 4–6 weeks apart); multiple bands can be placed with local anaesthesia
• Post-procedure: Sitz baths, acetaminophen for discomfort
• Complications: Pain (band too distal), bleeding (up to 2 weeks), rare pelvic sepsis
• Contraindications: Anticoagulation, immunocompromise (use caution), external haemorrhoids

B. Injection Sclerotherapy

• Grades: I–IV (preferred in immunocompromised/HIV patients with CD4 >200; effective even in Grades III–IV in this group)
• Agent: 5% phenol in oil or hypertonic saline
• Success rate: ~75%
• Mechanism: Causes submucosal fibrosis fixing the vascular cushion
• Advantage: Can be used in patients on anticoagulation or with portal hypertension

C. Infrared Photocoagulation (IRC)

• Grades: I–II
• Technique: Infrared energy applied to the base of the haemorrhoid
• Success rate: 67–80%
• Advantage: Minimal pain, quick office procedure

D. Other Office Procedures

• Cryotherapy — Rarely used; prolonged healing, discharge
• Bipolar/direct current electrocoagulation — Grade I–II
• Radiofrequency coagulation — Newer technique, Grade I–III

Treatment Options Summary Table (Internal Haemorrhoids)

Step 3 — Surgical Management

A. Excisional Haemorrhoidectomy

• Types:
  • Milligan-Morgan (open): Haemorrhoidal tissue excised, wound left open to heal by secondary intention
  • Ferguson (closed): Wound closed with absorbable sutures
• Success rate: >90%; most durable
• Main drawback: Significant postoperative pain
• Pain management adjuncts:
  • Topical glyceryl trinitrate
  • Topical anaesthetic creams
  • Topical sucralfate
  • Topical metronidazole (shown to reduce post-op pain in systematic review, PMID 39117876)
  • Liposomal bupivacaine (long-acting local anaesthetic)

B. Procedure for Prolapsing Haemorrhoids (PPH) / Stapled Haemorrhoidopexy

• Grades: II–IV (best results in II–III)
• Technique: Circular stapler excises a circumferential ring of mucosa above the anorectal ring, interrupts vascular supply, and restores prolapsing tissue
• Advantage: Significantly less postoperative pain than excisional haemorrhoidectomy
• Complications: Bleeding, urinary retention, severe persistent pain (if staple line too close to dentate line), urgency (~28%), rare pelvic sepsis
• Note: More patients in PPH group required subsequent haemorrhoidectomy for persistent symptoms vs. excisional surgery

C. Doppler-Guided Haemorrhoid Artery Ligation (DGHAL / THDL)

• Grades: II–III
• Technique: Doppler probe identifies haemorrhoidal arteries; suture ligation performed without excision
• Advantage: Less pain than excision; comparable results to PPH

D. Laser Haemorrhoidoplasty

• Grades: II–III
• Recent evidence: A 2024 meta-analysis (PMID 38762410) found diode laser haemorrhoidoplasty had comparable efficacy to Milligan-Morgan/Ferguson haemorrhoidectomy with significantly less postoperative pain and earlier return to activity

Step 4 — External Haemorrhoids & Thrombosed Haemorrhoids

Non-Thrombosed External Haemorrhoids

• Conservative management: sitz baths, stool softeners, topical analgesics
• No surgical excision required unless symptomatic and unresponsive

Acute Thrombosed External Haemorrhoid

• If ≤72 hours from onset + severe pain:
  • Office excision under local anaesthesia (1% lidocaine with epinephrine)
  • Technique: Elliptical skin excision with enucleation of entire clot; wound left open (simple incision alone has high recurrence)
  • Provides rapid, definitive relief
• If >72 hours or pain already subsiding:
  • Pain typically self-resolves in 4–7 days
  • Conservative: sitz baths, oral analgesics (NSAIDs), topical witch hazel
  • Outcome at 2 months is equivalent with or without excision at this stage

Special Situations

Pregnancy

• Conservative management preferred throughout pregnancy: fibre, fluids, stool softeners, topical local anaesthetics
• Rubber band ligation is safe in refractory cases
• Surgery reserved for acute prolapse with strangulation only
• Haemorrhoids typically improve post-partum but often do not fully resolve

HIV/Immunocompromised

• CD4 >420/mm³: RBL with good results
• CD4 <200: Avoid surgery due to poor wound healing; prefer sclerotherapy
• Bowel preparation + antibiotic prophylaxis in diabetic/immunocompromised patients before RBL

Anticoagulated Patients

• Sclerotherapy preferred over RBL
• For elective surgery: manage anticoagulation per standard perioperative protocol
• Acute haemorrhoidal bleeding: control by suture ligation

Crohn's Disease

• Avoid surgical excision of perianal skin tags (risk of non-healing, ulceration, recurrence)
• Medical management preferred

Monitoring & Follow-up

• All patients: Reassess after 4–6 weeks of conservative therapy
• Post-RBL: Follow-up at 4–6 weeks; repeat banding if needed (most managed in ≤3 sessions)
• Post-haemorrhoidectomy: Routine wound checks; watch for urinary retention, bleeding, infection
• Recurrence prevention: Sustained high-fibre diet, adequate hydration, and avoidance of straining indefinitely
• Patients >40 years with haemorrhoidal bleeding: rule out concurrent colorectal pathology with sigmoidoscopy or colonoscopy

When to Refer / Escalate

• Failure of conservative + office treatment
• Grade III–IV haemorrhoids
• Acute prolapse/strangulation
• Haemorrhoidal bleeding refractory to outpatient treatment
• Suspected concurrent colorectal pathology
• Thrombosed haemorrhoids within 72 hours with severe pain
• Haemorrhoids in Crohn's disease (colorectal surgery referral)