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Haemorrhoids

Essentials

  • Haemorrhoids are a consequence of the enlargement and prolapse of the so-called anal cushions, i.e. the blood vessel-rich soft tissues around the anal canal.
  • Symptoms associated with haemorrhoids are common and usually self-limited, but they tend to recur.
  • Surgery is usually reserved only for patients with persistently prolapsed (grade IV) haemorrhoids.

Symptoms

  • Rectal bleeding is the most common complaint (haematochezia). Ask the patient about the type of bleeding (visible on toilet paper, soiling the pants, dripping after defecation). Blood mixed in faeces is suggestive of a tumour.
  • Other symptoms include uncomfortable feeling, itching or problems with personal hygiene. Pain is more likely to be caused by perianal haematoma, thrombosed haemorrhoids, or anal fissure.

Diagnosis

  • Visual inspection
    • Observe for external skin tags, anal fissure, tumours
  • Digital rectal examination
    • Note the resting tone, force of contraction and presence of tumours
  • Proctoscopy
    • Without bowel preparation during the appointment. The grade of the haemorrhoids may be assessed by asking the patient to strain with the proctoscope in situ. With the patient straining withdraw the proctoscope, and any haemorrhoids will prolapse through the anal orifice with the scope.
  • Sigmoidoscopy/colonoscopy
    • Before any treatment is instigated, at least a sigmoidoscopy must be carried out in all patients who have had rectal bleeding. Patients over 50 years of age are recommended to undergo colonoscopy to exclude carcinoma and adenoma. For melaena see Examining a Patient with Rectal Bleeding.

Differential diagnosis

  • Anal fissure Anal Fissure
    • Painful; situated dorsally; may be palpated on digital rectal examination (lidocaine gel necessary for the examination).
  • Perianal abscess Anal Abscess
    • Incision preferably under general anaesthesia.
  • Perianal fistula
    • Surgery often indicated.
  • Mucosal prolapse
    • Prolapse of the rectal mucous membrane outside the anal canal. Diagnostics are the same as for haemorrhoids. Radial mucosal folds are apparent on visual inspection.

Grading

  • Grade I: congested anal cushions
  • Grade II: protrude up to the anal orifice with straining, but reduce spontaneously into the anal canal
  • Grade III: protrude outside the anal canal, and require manual reduction
  • Grade IV: remain prolapsed outside the anal orifice (picture 1)

Treatment Conventional Versus Ligasure Hemorrhoidectomy for Patients with Symptomatic Hemorrhoids

Treatment strategies

GradeManagementAlternatives
Asymptomatic haemorrhoidsNo treatment
Symptomatic grade I-IIRubber band ligationCreams, dietary fibre
Symptomatic grade IIIRubber band ligation × 3-4Sitz baths, dietary fibre, surgical excision
Symptomatic grade IVSurgical excision http://www.dynamed.com/condition/hemorrhoids#EXCISIONAL_SURGERY
Bleeding haemorrhoids or patients with hepatic cirrhosis or coagulopathiesRubber band ligationSclerotherapy http://www.dynamed.com/condition/hemorrhoids#SCLEROTHERAPY, (surgical treatment)

Rubber band ligation

  • Video Rubber Band Ligation for Haemorrhoids Using a Suction Instrument
  • Can be performed by general practitioner.
  • Use a banding instrument with suction (not forceps).
  • A headlamp may be used as the light source.
  • The suction cup of the instrument is inserted through a proctoscope at least 3 cm into the rectum (ca. 1 cm above the dentate line) on the haemorrhoid or over a site proximal to the haemorrhoid if it is located lower. A ligature closer to the anal orifice is painful and should be avoided.
  • After the cup has been positioned in the right place, turn the suction on, and suction the mucosal fold containing the hemorrhoid tissue into the cup. Trigger the ligation band. Turn the suction off and detach the suction catheter from the instrument. Withdraw the instrument gently together with the proctoscope.
  • Reinsert the proctoscope to check the correct positioning of the rubber band (a "blueberry" can be seen if the procedure was successful).
  • Up to three haemorrhoids can be ligated at the same occasion.
  • The ligated haemorrhoids or mucosal folds will fall out within a week, and any haemorrhoids below the ligature will atrophy as their venous connection have been severed.
  • The procedure can be repeated 3-4 times within an interval of one month if residual hemorrhoids exist. If the symptoms still persist after this, surgery should be considered.
  • Complications are rare, but may include bleeding and infection of the adjacent rectal tissue.

Strangulated haemorrhoids

  • Strangulated haemorrhoids (acute haemorrhoidal crisis) require hospital treatment. The onset is abrupt with severe pain. Accompanying mucosal prolapse will contribute towards mucous discharge and bleeding.
  • The diagnosis is apparent on inspection.
  • Conservative treatment with sitz baths, showering and topical creams may be used if the blood circulation to the haemorrhoids is preserved. The treatment can also be carried out at home provided that the patient is not in need of inpatient care due to pain. As the swelling has subsided the haemorrhoids will usually draw back in and, if necessary, the remaining external components can be surgically removed under local anaesthesia.
  • Urgent operation is warranted for strangulated haemorrhoids (dark-coloured, gangrenous).

Perianal haematoma ("thrombosed haemorrhoids")

  • Perianal haematoma occurs when a venous plexus, or subcutaneous haematoma, becomes thrombosed and acutely painful and forms a hard, dark red blister.
  • Treatment: Infiltrate a small area of the skin with 1% lidocaine and make an incision with a narrow-tipped scalpel (video Thrombosed Haemorrhoid (Anal Haematoma)). Evacuate the clot by gently pressing with fingers or by curettage. Any bleeding can be controlled by compression.
  • After the procedure, the patient should be advised to wash the area 1-3 times daily.

Rectal prolapse

  • Rectal prolapse refers to the prolapse of the entire rectal muscular wall outside the anal orifice. The prolapse is accompanied by pain, mucous discharge and bleeding.
  • The condition is most common in individuals aged 60-70 years. The majority of the patients are women.
  • Often associated with gynaecological prolapses and hence gynaecological examination is essential. A gynaecological prolapse can be treated simultaneously during surgery for rectal prolapse.
  • Predisposing factors for rectal prolapse include damage to and degeneration of muscular tissue, childbirths and pregnancies, alterations in neural function and connective tissue changes. Hormonal factors also have an effect.
  • A total rectal prolapse will not reduce spontaneously in adults, but requires surgery. A prolapse of the rectal mucosa alone can usually be treated with repeated rubber band ligations.