What is Haemorrhoids (Piles; Hemorrhoids)

Haemorrhoids or piles are located in the anus. The term when used in a clinical sense, refers to the internal disruption or downward displacement of the anal cushions. The anal cushions are tissue structures rich in blood supply, that line the anus and contribute to anal closure.

They are classified according to their clinical presentation:

  • First degree haemorrhoids occur when the is some bleeding present.
  • Second degree heamorrhoids refer to spontaneously reducing prolapse of the anal cushions during defaecation.
  • Third degree haemorrhoids refers to prolapse requiring manual replacement.
  • Fourth degree haemorrhoids indicates permanent prolapse. Haemorrhoids may be referred to as internal or external, depnding on the location of the prolapse.

Haemorrhoids are often defined as varicosity of the anal veins causing engorgement. This definition is incomplete, as although commonly defined through the clinical presentation of bleeding, haemorrhoids actually refer to the prolapse of the anal cushions.

Statistics on Haemorrhoids (Piles; Hemorrhoids)

Up to 4% of the population may have haemorrhoids. Many patients often do not present to health care facilities due to embarassment or the fact that the haemorrhoids spontaneously resolve. The peak age of occurence is 45-65 years, however, they can occur at any age.

Risk Factors for Haemorrhoids (Piles; Hemorrhoids)

The anal cushion often prolapse due to engorgment of the blood vessels within them.

Factors that may predispose an individual to haemorrhoids may include: excessive straining on defecation, constipation, inflammatory bowel disease, pregnancy, colon cancer, liver disease, loss of muscle tone, occupational (prolonged sitting), obesity and chronic diarrhoea.

Progression of Haemorrhoids (Piles; Hemorrhoids)

First and second degree internal haemorrhoids may present with rectal bleeding, a lump, discharge, or itching. They may not progress to third or fourth degree haemorrhoids, especially if the patient improves the fibre and fluid content of his/her diet. Haemorrhoids may also present acutely with severe pain as they protrude through the anus and cause the anal sphincter to spasm.

A positive “vicious cycle” can be responsible for progression of this episode. As the vascular cushions protrude through a tight anus, they become more congested, which may cause further protrusion, eventually causing the haemorrhoids to strangulate (cut off blood supply) – causing further severe pain and become difficult to be reduced. Eventually the haemorrhoids will ulcerate.

External haemorrhoids similarly may suddenly rupture – usually after straining at stool or heavy lifting. This usually causes thrombosis of the vein – and a painful swollen lump. The skin overlying the thrombosed vein can ulcerate – and eventually with healing a “skin tag” may be all that remains.

How is Haemorrhoids (Piles; Hemorrhoids) Diagnosed?

  • Full blood count – if anaemia is suspected.
  • Older patients (>50), as well as those with significant family history of colon cancer or significant anaemia also reqiure either:
  • Colonoscopy. This allows for inspection of the whole of the colon and biopsies of any suspicous lesions;
  • A sigmoidoscopy may be preferrable. Although it only examines the distal 2/3 of the colon – it requires less preparation of the bowel, and any cause of PR bleeding will almost always be in that part of the bowel.
  • A double contrast Barium Enema is often combined with a sigmoidoscopy.

Prognosis of Haemorrhoids (Piles; Hemorrhoids)

Haemorrhoids are a chronic condition – but they are treatable.

Lower degrees of haemorrhoids (first and second) usually resolve but they can progress, especially if the risk factors – (constipation, straining, hard stools) are not addressed. Higher degrees usually require treatment.

Acutely strangulated or thrombosed haemorrhoids can subside on their own over a few days – and surgeons are divided on whether to operate on them immediately, as haemorrhoidectomy (surgery to treat haemorrhoids) can have complications.

Recurrence rates are estimated to be 10-50% over 5 years.

How is Haemorrhoids (Piles; Hemorrhoids) Treated?

All patients should be treated conservatively through techniques such as avoiding prolonged straining, increasing fibre and fluid intake and the use of stool softeners. If these technqiues are inadequate, there are many other interventional options ranging from cryotherapy (using liquid nitrogen to freeze off the piles) to haemorrhoidectomy (surgery to remove the pile). Warm baths, pain relief and bed rest are often a good starting point.

 

Haemorrhoids (Piles; Hemorrhoids) References

  1. Davidson S, Haslett C. Davidson’s Principles and Practice of Medicine (19th edition). Edinburgh: Churchill Livingstone; 2002. Book
  2. Hurst JW (ed). Medicine for the Practicing Physician (4th edition). Stamford, CT: Appleton and Lange; 1996. Book
  3. Longmore M, Wilkinson I, Török E. Oxford Handbook of Clinical Medicine (5th edition). Oxford: Oxford University Press; 2001. Book
  4. McLatchie G, Leaper DJ (eds). Oxford Handbook of Clinical Surgery (2nd edition). Oxford: Oxford University Press; 2002. Book
  5. Morris PJ, Wood WC. Oxford Textbook of Surgery (2nd edition). Oxford: Oxford University Press; 2000. Book
  6. Raftery AT. Churchill’s Pocketbook of Surgery (2nd edition). Edinburgh: Churchill Livingstone; 2001. Book