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Haemorrhoids

Description

Haemorrhoids (or piles) are vascular internal cushions that reside in the anal canal. They are, in fact, a normal part of our anatomy and have a small role in maintaining bowel continence (control).

Internal Haemorrhoids

These are true haemorrhoids that can cause symptoms such as rectal bleeding, prolapse (protrusion), itch and perianal discomfort. Bleeding is usually bright red, painless and separate from the stool. Uncomplicated internal haemorrhoids can be graded as follow

  • Grade 1 – Bleeding only
  • Grade 2 – Prolapse that spontaneously goes back in
  • Grade 3 – Prolapse that needs to be pushed back in
  • Grade 4 – Prolapse that can’t be pushed back in

Severe pain is not usually a feature of internal haemorrhoids unless they become prolapsed and strangulated (lose blood supply) or thrombosed ( a clot develops in the vein).

External Haemorrhoids (Perianal Haematoma)

This is a painful external perianal lump that develops acutely usually after straining at stool or during exrercise(but not always). It is not a true haemorrhoid but often referred to as one. It is different from an internal haemorrhoid that prolapses and becomes external.

Skin tags

People often have excess skin at the anal verge and they quite often mistake these for haemorrhoids. They arise usually from previous haemorrhoids (or other perianal conditions) that have stretched the perianal skin. They often cause no symptoms and do not require treatment. Some people are bothered by them and find it hard to clean the perianal area after a motion. The only treatment is surgical excision.

Causes

As noted above, all people have haemorrhoids. There are risk factors that lead to haemorrhoids becoming symptomatic. Any change in healthy bowel habits can lead to symptomatic haemorrhoids. This includes straining to defaecate, constipation, spending a long time on the toilet, excessive loose motion. Very strenuous exercise is another risk as well as pregnancy because of the weight of the uterus and hormonal changes.

Assessment

Haemorrhoids can usually be diagnosed by inspection of the anal area, a digital examination and proctoscopy (a small scope into the anus). As ‘haemorrhoidal symptoms’ such as bleeding can be also present in more sinister pathologies such as colorectal cancer, a colonoscopy is usually recommended especially in patients over 40 years.

Treatment

In all cases, it is important to correct abnormal bowel habits and a poor diet low in fibre. Bulking agents such as Metamucil, psyllium husk or benefiber are often all that is required to correct constipation. People should only defaecate when they have a strong urge and spend as short amount of time as possible on the toilet. Regular exercise and a good fluid intake (1.5 – 2L/day) is important.

Topical Agents

There are multiple over the counter topical creams, ointment and suppositories that contain a mixture of local anaesthetic, steroid and antiseptic. Such agents include proctesydyl, rectinol and anusol. These can relieve irritation, itch and swelling temporarily. They have not been shown to be greatly effective in trials and should not be used long term.

Procedures

There are multiple procedures described to treat haemorrhoids. These include

  • Rubber Band Ligation – An office based procedure performed quickly, this is very effective for the symptom of bleeding. It can also be used for mild to moderate prolpase
  • Haemorrhoidal Injection – An office based procedure where oily phenol is injected into the haemorrhoid to close small blood vessels. This is used for bleeding especially in patients that are on blood thinning medications that cannot be stopped.
  • Stapled Haemorrhoidopexy – This requires a general anaesthetic and was developed to reduce the discomfort after haemorrhoidectomy. Its is good for circumferential haemorrhoids and grade 2 or 3 internal haemorrhoids.
  • HAL – RAR – Haemorrhoid Artery Ligation – Recto Anal Repair – This requires a general anaesthetic. The arteries feeding the haemorrhoids are sutured and then the haemorrhoids are sutured to higher up in the anal canal. This was also developed to decrease the pain after haemorrhoidectomy. The medium and long term outcomes are uncertain.
  • Open Haemorrhoidectomy (Milligan-Morgan) – This is still the gold standard in the treatment of grade 3 and 4 haemorrhoids. It has the best long term outcomes, the major drawback is that post-operative pain can be quite severe for 1 – 4 weeks.
  • Prince of Wales Private Hospital
  • The Royal Hospital For Women Foundation
  • Colorectal Surgical Society of Australia and New Zealand
Randwick Rooms

Prince of Wales Private
Suite 17, Level 7
Barker Street
Randwick NSW 2031

Phone: 1300 553 347
Fax: (02) 9650 4924

Double Bay

Double Bay Day Hospital Specialist Suites
Suite 3.01, Level 3, commercial
451 New South Head Road
Double Bay

Phone: 0290 863 133
Fax: (02) 9086 3123

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