Haemorrhoids are vascular-rich connective tissue cushions located within the anal canal. Internal haemorrhoids lie proximal to the dentate line in the anal canal; external haemorrhoids are located distal to the dentate line.
Haemorrhoidal disease presents as painless rectal bleeding or sudden onset of perianal pain with a tender palpable perianal mass.
Diagnosis is confirmed with visualisation of the protruding tissue or anoscopic visualisation.
Treatment for all patients includes increasing dietary fibre. Rubber band ligation is a reasonable first-line treatment choice for grade 2 and 3 internal haemorrhoids. Other treatment options for grade 2 or 3 haemorrhoids include sclerotherapy, infrared coagulation, haemorrhoid arterial ligation, or stapled haemorrhoidopexy. Surgical haemorrhoidectomy may be considered for patients with large grade 3 haemorrhoids, but it is typically reserved for patients with grade 4 haemorrhoids.
Complications include recurrence or worsening of symptoms, excessive bleeding, non-reducible prolapse, and, rarely, pelvic sepsis.
Haemorrhoidal cushions are normal anatomical structures located within the anal canal, usually occupying the left lateral and right anterior and posterior positions. As they enlarge, they can protrude outside the anal canal causing symptoms.
History and exam
Key diagnostic factors
- presence of risk factors
- rectal bleeding
- intermittent protrusion
- perianal pain/discomfort
Other diagnostic factors
- anal pruritus
- tender palpable perianal lesion
- anal mass
- age between 45-65 years
- pregnancy or space-occupying pelvic lesion
- hepatic insufficiency
1st investigations to order
- anoscopic examination
- colonoscopy/flexible sigmoidoscopy
- stool for occult haem
all patients at presentation
treatment failure of rubber band ligation, sclerotherapy, infrared coagulation, transanal haemorrhoidal de-arterialisation, or stapled haemorrhoidopexy
- Anal fissure
- Crohn's disease
- Ulcerative colitis
- ACG clinical guidelines: management of benign anorectal disorders
- The European Society of Coloproctology: guideline for haemorrhoidal disease
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