Haemorrhoids
Haemorrhoids (piles) are abnormally swollen vascular mucosal cushions that are present in the anal canal. They are classed as external or internal, depending on their origin in relation to the dentate line.
Bright-red, painless rectal bleeding with defecation is the most common symptom.
Pain is rarely felt with haemorrhoids unless a pile has strangulated +/- thrombosed.
Who to refer:
Patients who are significantly symptomatic, affecting quality of life, despite trying treatments outlined in the Primary Care Management Section
Patients where there is diagnostic uncertainty
Persistent or heavy pr bleeding
Thrombosed piles with persistent pain
Perianal sepsis
How to refer:
Via Sci Gateway to Colorectal Surgeons
Treatment in Primary Care
Thorough assessment:
Risk factors include constipation, prolonged straining and time on the toilet, increased abdominal pressure as in ascites or during pregnancy and childbirth, heavy lifting, chronic cough and ageing.
Exclude red flags.
Perform a PR examination to visualise external piles. Local perineal irritation may be seen if chronic mucous discharge is present. Patients should have a digital rectal examination to exclude any other pathology.
Self help measures to advise patients
Aim to pass stools of a soft, “toothpaste-like” consistency.
Increase daily intake of fibre. Avoid dehydration. Aim for 1.5-2 litres’ fluid per day.
Get more exercise.
Don’t put off going to the toilet until later. Avoid straining to pass a stool. Avoid sitting on the toilet for too long and limit the time to 5 minutes.
Review of medications with GP or Pharmacist to check if any are causing constipation.
Medications
Laxatives
Stool softeners (such as Lactulose) are helpful. Consider adding in another laxative, such as Macrogol, if constipation needs treated.
Topical anaesthetics and steroids
Anaesthetic preparations (creams, ointments, foams sprays or suppositories) may alleviate pain, burning and itching. These should normally only be used for up to 7 days, as they may cause irritation of the anal skin with longer use.
Steroid preparations (usually in combination with local anaesthetic) can help if there is inflammation around the piles. This may help ease itch and pain. Again, these should not normally be used for longer than a week at a time.
Most medications are to be used morning and night and after opening the bowels. Topical preparations that come with an applicator and suppositories are better at treating “internal piles”.
Other treatments
Most piles do not require treatment beyond what is described above. Only about 10% of people will eventually need surgery.
Rubber band ligation
Small rubber bands are placed at the base of the pile. This cuts off the blood supply to the pile which then dies and drops off after a few days. This can often be done at the same time as endoscopy.
Haemorrhoidal Artery Ligation Operation (HALO)
This procedure is good for patients with more significant bleeding. This is done under general anaesthetic, usually as a day case procedure.
Haemorrhoidectomy
If the piles are too big for the banding treatment (or it doesn’t work), and are causing significant problems, the piles can be surgically removed. This is done under general anaesthetic, usually as a day case procedure.
