Haemorrhoids
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Direct answer
Haemorrhoids are vascular cushions of the anal canal arising from the superior haemorrhoidal plexus. Internal haemorrhoids lie above the dentate line under mucosa and classically cause painless bright-red bleeding with prolapse; external haemorrhoids lie below the dentate line under sensitive skin and hurt, especially when thrombosed. Treatment begins with fibre, fluids and avoiding straining, escalating through rubber band ligation to haemorrhoidectomy for advanced prolapse.
What you must remember
- Goligher grading — grade I bleed only; grade II prolapse on straining and reduce spontaneously; grade III need manual reduction; grade IV are irreducible.
- Internal haemorrhoids occur classically at 3, 7 and 11 o'clock in the lithotomy position — the primary positions supplied by the terminal branches of the superior rectal vessels.
- Painless bright-red blood coating the stool or dripping after defaecation is typical; significant pain points instead to a fissure, perianal abscess or a thrombosed external pile.
- Office procedures — rubber band ligation is the treatment of choice for grades I to III, along with injection sclerotherapy with 5 per cent phenol in almond or arachis oil and infrared coagulation.
- Surgery — open Milligan-Morgan or closed Ferguson haemorrhoidectomy for grades III and IV; stapled haemorrhoidopexy for circumferential prolapse.
- An acutely thrombosed external haemorrhoid is an exquisitely painful perianal lump; excision or evacuation helps if performed within the first 48-72 hours, otherwise manage with analgesia, ice packs and sitz baths.
- Never attribute rectal bleeding to piles without proctoscopy — and add colonoscopy for older patients or those with altered bowel habit, anaemia or weight loss to exclude colorectal cancer.
Common confusion
Haemorrhoids and anal fissures are the perennial mix-up. Piles are painless bleeders that prolapse; a fissure is a painful linear ulcer with severe post-defaecation burning, a sentinel tag and often a spasm-induced constipation cycle. First-line fissure care is stool softening, sitz baths and topical glyceryl trinitrate or diltiazem — not banding. Also keep the dentate line straight: above it, internal haemorrhoids are insensate mucosa; below it, external haemorrhoids are painful skin-covered cushions.
Exam-focused takeaway
Grading questions dominate — match the Goligher grade to its procedure: banding for grades II-III, haemorrhoidectomy for grades III-IV. Know phenol sclerotherapy by its chemical name and concentration, the 3-7-11 primary positions, and the red-flag rule that bleeding per rectum demands examination before it is blamed on piles. Image questions may show a thrombosed external pile or a prolapsed grade IV pile.
Frequently asked questions
How are internal haemorrhoids graded and treated?
Grade I bleed only, grade II reduce spontaneously, grade III need manual reduction and grade IV cannot be reduced. Treatment escalates from fibre and banding to haemorrhoidectomy.
What is the treatment of choice for second-degree haemorrhoids?
Rubber band ligation, combined with dietary fibre and fluid. It strangulates the cushion, causing fixation and atrophy over a week or so.
Why are internal haemorrhoids painless?
They arise above the dentate line, which is lined by insensate columnar mucosa supplied by visceral autonomic nerves. External haemorrhoids under sensitive anoderm are painful.
How is a thrombosed external haemorrhoid managed?
Within about 48-72 hours of onset, excision or clot evacuation under local anaesthesia relieves pain. Later, the clot organises and conservative care with analgesia and sitz baths is preferred.
When should rectal bleeding not be attributed to piles?
When there is anaemia, weight loss, altered bowel habit, age over about 50 years, or dark bleeding mixed with stool. Proctoscopy and colonoscopy are then mandatory to exclude cancer.