Haemorrhoids (Piles)

Definition & Anatomy

• Internal haemorrhoids: originate above the dentate line, covered by columnar/transitional mucosa. Classically in the 3, 7, and 11 o'clock positions (patient in lithotomy position).
• External haemorrhoids: originate below the dentate line, covered by squamous epithelium, relating to the inferior haemorrhoidal plexus.

Pathophysiology

1. Man's upright posture and absence of valves in the portal venous system
2. Raised intra-abdominal pressure - straining at defecation, constipation, pregnancy, portal hypertension
3. Shearing forces during defecation cause mucosal trauma (bleeding) and caudal displacement of the anal cushions (prolapse)
4. Impaired venous drainage leads to progressive engorgement, local stasis, and transudation (causing pruritus)
5. Fragmentation of supporting structures (normal ageing, possibly accelerated) causes loss of cushion elasticity - they no longer retract after defecation
6. Symptoms correlate with increased circulating matrix metalloproteinases that degrade connective tissue

Classification / Grading

Internal Haemorrhoids - 4 Grades:

Clinical Features

• Bleeding: the earliest and most characteristic symptom. Bright-red, painless, separate from the stool - seen on the paper or as a splash in the pan. Rarely causes anaemia.
• Prolapse: lumps appearing at the anal orifice during defecation (Grade II-IV).
• Pruritus: due to mucus discharge and perianal moisture from prolapsing tissue.
• Pain: usually absent with uncomplicated internal haemorrhoids. Pain should prompt search for another diagnosis (e.g. anal fissure, abscess, thrombosis).
• Thrombosed external haemorrhoid: presents as sudden-onset, olive-shaped, painful blue subcutaneous swelling at the anal margin - often after straining, coughing, or heavy lifting. Also called a perianal haematoma.

Important: Patients frequently attribute all anal symptoms to haemorrhoids. In clinical practice, many presenting with "haemorrhoids" have another diagnosis (fissure, pruritus ani, warts, carcinoma). Haemorrhoids in an atypical location should raise concern for carcinoma, lymphoma, or condyloma.

Investigation

• History and examination (inspection, digital rectal examination)
• Anoscopy (proctoscopy): using a beveled or slotted anoscope - primary tool for visualising and grading internal haemorrhoids
• Exclusion of colorectal malignancy is the first priority before attributing symptoms to haemorrhoids
• Sigmoidoscopy/colonoscopy when indicated

Management

1. Conservative / Lifestyle Measures

• Improve bowel habits; avoid straining; adopt correct defecatory posture
• High-fibre diet, stool softeners, bulking agents
• Topical creams and suppositories (reduce local symptoms)
• Phlebotonics (flavonoid extracts, e.g. diosmin/hesperidin; calcium dobesilate): reduce capillary permeability and increase lymphatic drainage. A 2024 meta-analysis (PMID 38847122) confirmed flavonoids improve post-haemorrhoidectomy recovery.

2. Office / Outpatient Procedures (Grades I-II, some III)

3. Surgical Procedures (Grades III-IV, failed conservative/office)

• Grade III and IV haemorrhoids
• Grade II not cured by non-operative treatments
• Mixed haemorrhoids with a well-defined external component
• Bleeding causing anaemia

• Open technique (Milligan-Morgan): Most common in the UK. V-shaped skin incision, dissection to the pedicle, transfixion ligation with strong Vicryl, pile excised. Wound left open to heal by secondary intention. Mucocutaneous bridges must be preserved.
• Closed technique (Ferguson): Popular in the USA. Same principle but wound is sutured.
• Stapled Haemorrhoidopexy (PPH): Circular stapling device excises a 3-4 cm strip of mucosa/submucosa above the dentate line, repositioning haemorrhoids and interrupting blood supply. Less painful, quicker recovery - but higher recurrence rates. Rare but serious complications include staple line dehiscence, rectovaginal fistula, and tenesmus.
• Transanal Haemorrhoidal Ligation (HAL/HALO): Doppler-guided ligation of feeding vessels ± mucopexy. The HubBLe trial showed lower recurrence than RBL but lower cost-effectiveness.

4. Thrombosed External Haemorrhoid

• If presenting within 48 hours: evacuation of clot under local anaesthesia is appropriate.
• If presenting later: conservative management - the haematoma usually resolves or fibroses spontaneously.
• A 2026 systematic review (PMID 40576944) found operative treatment reduces time to pain relief but outcomes converge at 4 weeks.

Complications of Haemorrhoidectomy

• Post-operative bleeding (primary, reactionary, secondary)
• Urinary retention (common)
• Anal stenosis (if skin bridges not preserved)
• Faecal impaction
• Sepsis / pelvic sepsis (rare but serious)
• Incontinence (if sphincter damaged)

Special Considerations

• Pregnancy: haemorrhoids are common due to venous stasis and raised intra-abdominal pressure. Conservative management is preferred; most resolve post-partum.
• Portal hypertension: haemorrhoids develop via portosystemic collaterals. Haemorrhoidal bleeding can be more significant; treat the underlying portal hypertension.

• Bailey and Love's Short Practice of Surgery, 28th Ed., Ch. 80
• Sleisenger and Fordtran's Gastrointestinal and Liver Disease
• Robbins & Kumar Basic Pathology
• Recent PubMed meta-analyses: PMID 38847122, PMID 40596934, PMID 40576944