•           Haemorrhoids (commonly called Piles) are the dilated tortuous veins occurring in relation to the anus.

•           These can be primary or secondary to some other disease like carcinoma of rectum, pregnancy, straining at micturition, or constipation due to any cause.

•           These can be classified into external, internal or mixed (externo-internal) depending on their position in relation to anal orifice.

•           Internal haemorrhoids are classified as -

1.      First degree- Bleed, but do not prolapse

2.      Second degree -Spontaneous prolapsing and reducing with or without bleeding

3.      Third Degree- Prolapsing, that requires manual reduction

4.      Fourth Degree - Prolapsed, cannot reduce

Salient Features

•           Patients can present with bleeding - it is bright red in colour, occurs as splash in pan during defecation, mass per rectum, mucus discharge, pruritus, pain, anaemia.

•           On digital rectal examination only thrombosed pile can be felt. If there is hard mass on rectal examination than it is further investigated.

•           On proctoscopy- exact position can be made out as bulge into the proctoscope.

•           Complications of haemorrhoids include strangulation, thrombosis, ulceration, gangrene, fibrosis, suppuration and pyelophlebitis.

Treatment

•           Asymptomatic haemorrhoids do not need any treatment

•           Secondary haemorrhoids due to concomitant disease also tend to resolve once the underlying disease is cured.

•           First-degree haemorrhoids- Dietary fibre, avoid straining during defecation, sitz baths. Rubber band ligation, sclerosis, and thermotherapy by using infrared beam, electric current, CO2 laser, or ultrasonic energy is used in first- or second-degree haemorrhoids.

•           Operative haemorrhoidectomy is reserved large third and fourth-degree haemorrhoids, mixed haemorrhoids with a prominent external component.

•           The complications of surgery include pain, acute retention of urine, reactive bleeding and later on secondary haemorrhage and anal stricture.

Patient education

•           Avoid constipation and use laxative, if required. Use high fiber diet that produces high roughage. Sitz bath to reduce pain and spasm.

•           Haemorrhoids that prolapsed should be reposed gently and not forced back. Take treatment for any disease that promotes straining at micturition like benign hypertrophy of prostate.