7.1.2 Haemorrhoids

Piles.

Most common anorectal pathology diagnosed in clinical practice. The prevalence of symptomatic hemorrhoids is estimated at 4.4 %. In both sexes, peak prevalence is around  the age 45-65 years.

Symptomatic enlargement and distal displacement of the normal anal cushions resulting from swollen blood vessels in the anus and lower rectum; most common causes of anorectal complaints.

The theory of sliding anal canal lining is widely accepted. Degradation of matrix by matrixmetalloproteinases and loss of elastic fibers occurs. Hemorrhoidal venous cushions have therefore a predisposition to dilate and prolapse. Multifactorial origin: including decreased venous return (low-fiber diets, small caliber stools), straining during defecation and constipation, multiple pregnancies and more rarely portal hypertension and anorectal varices.

Symptoms range from mild pruritus to fresh bright rectal bleeding. Possible other symptoms: pain, burning during or after defaecation, weeping, drainage of mucus, feeling of incomplete bowel movement, faecal urgency and anal venous thrombosis.

Most common sites (dorsal lithotomy position): 3, 7 and 11 o'clock on the anal ring. 

Four clinical degrees of severity:

Grade I hemorrhoids project into the anal canal, no prolapse.

Grade II hemorrhoids protrude beyond anal verge with straining or defecating but reduce spontaneously.

Grade III hemorrhoids protrude spontaneously and require manual replacement.

Grade IV hemorrhoids chronically prolapse and cannot be replaced.

Inspection, digital palpation; proctoscopy and rectoscopy.

Usually not needed. Clusters of vascular tissue, smooth muscle and connective tissue of the normal epithelium of the anal canal. Bleeding is of convoluted arterio-venous communicating vessel with bright colour.

Depending on degree,  they may consolidate or progress to stage III and IV. Most resolve spontaneously or with conservative medical therapy alone.

Irritative perianal dermatitis, haemorrhoidal vein thrombosis, secondary infection, ulceration, abscess, and incontinence.

Diagnosis is based on inspection and clinical examination. Proctoscopy or rectoscopy is important to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any new onset rectal bleeding in patients over 50 years of age or with atypical symptoms.

Anal fissure, perianal abscess, perianal fistulas and anal prolapse, anal skin tag or fibroma, rectal polyp, condylomata acuminata, vascular tumors including Kaposi sarcoma.

General measures: anal hygiene (soap-free cleansing after defaecation), natural regulation of bowel movements (high  fibre diet), adequate fluids, sufficient physical activity, no straining with defaecation. Lower pelvis muscle training.

The treatment options based on severity and grading:  

Grade I: conservative treatments (topical symptomatic treatment, increasing fiber intake, treatment of constipation) and avoidance of nonsteroidal anti-inflammatory drugs, spicy or fatty foods or fruit juices (orange, grapefruit). Topical treatments include corticosteroids and topical local anesthetics, menthol, astringents (e.g. ichthammol) and Sitz baths.

Grade II or III: Initial treatment with non-surgical procedures (e.g. sclerotherapy, infrared coagulation,  rubber band ligation).

Symptomatic grade III and grade IV: surgical hemorrhoidectomy

Treatment of grade IV hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation.

Severely bleeding haemorrhoids (e.g. due to portal hypertension, coagulopathies) can acutely be treated with rubber band ligation or sclerotherapy.