Haemorrhoids

• Anal cushions – located at 11, 3 and 7 o’clock (when in the lithotomy position)
• May become bulky and loose due to the effects of gravity, increased anal tone and straining at stool
• As there is no sensory fibres above the dentate line (squamomucosal junction) they shouldn’t hurt unless they protrude and are gripped by the anal sphincter blocking venous return

Differential

• Perianal haematoma
• Anal fissure
• Abscess
• Tumour
• Proctalgia fugax – idiopathic intense stabbing rectal pain

Causes

• Most commonly constipation
• Congestion from;
  • Pelvic tumour
  • Pregnancy
  • CCF
  • Portal hypertension

Pathogenesis

• Vascular cushions protrude through a tight anus becoming more congested so hypertrophying to protrude again more easily

• Do an abdo examination to exclude other diseases
• PR exam – prolapsing piles are obvious, internal haemorrhoids are not palpable
• Proctoscopy to see the internal haemorrhoids
• Sigmoidoscopy to identify rectal pathology higher up

Treatment

• Infra-red coagulation
• Sclerosant
• Rubber band ligation
• Cryotherapy
• Prolapsed thrombosed piles are treated with analgesics, ice packs and bed rest
  • Pain usually resolves in 2-3 weeks and surgery is seldom necessary

Classification of haemorrhoids

• 1^st degree – remain in rectum
• 2^nd degree – prolapse through the anus but spontaneously reduce
• 3^rd degree – as for 2^nd degree but require digital reduction
• 4^th degree – remain persistently prolapsed

• External haemorrhoid – origin below dentate line (external rectal plexus)
• Internal haemorrhoid – origin above dentate line (internal rectal plexus)
• Mixed haemorrhoid – origin above and below dentate line (internal and external rectal plexus)