Most patients with anal conditions complain of "piles" regardless of what anorectal symptoms they have. Haemorrhoids are enlarged, displaced anal vascular cushions.

SYMPTOMS

• Passage of bright red blood at defaecation

• Mucoid discharge

• Perianal irritation or itch

• Pain occurs only during an acute attack of prolapse with thrombosis, congestion and oedema

SIGNS

• Inspection of the anus may show no evidence of internal haemorrhoids

• Redundant folds of skin (skin tags) may be seen in the position of the haemorrhoids and straining may show the haemorrhoids

• Internal haemorrhoids are not palpable inside the rectum unless thrombosed

• The patient may present with a complication of the haemorrhoids e.g. profuse bleeding, prolapse, strangulation, thrombosis, infection or ulceration or severe anaemia

INVESTIGATIONS

• Full blood count
• Proctoscopy and sigmoidoscopy (to exclude carcinoma of rectum)

TREATMENT

Therapeutic objectives

• To correct any anaemia
• To relieve symptoms
• To prevent complications

Non-Operative Treatment

(Evidence rating: B)

• No treatment is required for haemorrhoids that are asymptomatic. Treat constipation if present with liquid paraffin, oral, 10-30 mls at night or Senna granules, 1 sachet with water after supper. Avoid the use of purgatives and prolonged straining at defaecation

• To relieve itch or discomfort, a range of ointments or suppositories are available as over the counter preparations. These include those with or without steroids, applied or inserted anally: one suppository 2 times daily for 7-10 days

• For prolapsed haemorrhoids, lie patient down and elevate the foot end of the bed. Try gentle digital reduction after application of local anaesthetic cream. If this fails, apply cold compresses and sedate patient with Diazepam, oral, 10 mg. If the haemorrhoids are infected, treat with Gentamicin, IV, 2-5 mg/kg body weight and Metronidazole, oral, 500 mg 3 times daily as well as warm sitz baths 2-3 times a day

• Correct any anaemia with iron preparation (ferrous sulphate) or blood transfusion if indicated

• Haemorrhoids developing during pregnancy should be managed conservatively as most will resolve after delivery. Increase intake of fluid and roughage

Bleeding Haemorrhoids

(Evidence rating: A)

• Correct anaemia with ferrous sulphate, oral or blood transfusion if indicated
• Give stool softners and increase roughage in diet if constipation is a problem

Indications for Operative Treatment

• Second degree haemorrhoids - These prolapse and have to be replaced in the anal canal manually but some may also reduce spontaneously.

• Third degree haemorrhoids - These are prolapsed permanently.

• Profuse or persistent bleeding haemorrhoids.

REFER

The patient should be referred to a facility with resources for operative treatment if this is indicated.