Haemorrhoids are swollen and engorged veins normally present in the lower rectum and around the anal opening. Due to certain precipitating factors, these veins become swollen and engorged with blood. The swollen veins together with the overlying tissue form swellings referred to as haemorrhoids or piles.

? TYPES OF HAEMORRHOIDS
• Internal haemorrhoids – Form in the lower portion of the rectum near the junction with the anal canal. These are not visible normally and are usually painless and asymptomatic

• Prolapsed haemorrhoids – Sometimes internal haemorrhoids prolapse to the exterior while passing stools or during walking or standing. These are painful

• External haemorrhoids – These form just 2-3 cms inside the anal opening and often bleed causing a hardened clot around the anal opening.

? CLASSIFICATION OF HAEMORRHOIDS
Piles or haemorrhoids can also be classified based on size, location and severity of symptoms

• Grade 1 are small swellings present in the anal canal. Normally, they are not visible or felt from outside. Grade 1 piles are common. Occasionally they may grow further to grade 2 or more.
• Grade 2 are larger in size. They may be partly pushed out through the anal opening when passing stools, but quickly go back inside again.
• Grade 3 piles remain outside and don’t go back in after passing stools. They may be felt as one or more small, soft lumps present around the anus. However, they can be pushed back inside with a finger.
• Grade 4 permanently hang down from within the anus, and cannot be pushed back inside. They can sometimes become quite big and painful.

? CAUSES AND RISK FACTORS OF HAEMORRHOIDS
• Straining at stool and constipation
• Chronic diarrhoea
• Chronic cough
• Older age – Tissue lining the anal canal becomes weak and less supportive with ageing
• Genetic – inherited weakness in the walls of the veins in the anal canal
• Prolonged sitting perhaps due to occupation eg drivers
• Heavy manual work
• Pregnancy
• Being overweight or obese

? SIGNS AND SYMPTOMS OF HAEMORRHOIDS
The signs and symptoms may vary depending on the location and severity of the haemorrhoids. Sometimes, they may be asymptomatic and painless. When symptomatic these include

Blood covering the stool, toilet bowl or staining toilet paper
Painful and hard lump around the anal opening in external piles
Permanent piles swelling around the anal opening that cannot be pushed back inside
Prolapse of internal haemorrhoids to the outside causing pain while passing stools
Itching and discomfort due to large haemorrhoids that may cause mucus discharge
Feeling of incomplete evacuation even after passing stools

? COMPLICATIONS OF HAEMORRHOIDS
Chronic bleeding resulting in anemia
Clotting of blood around the anus causing severe pain – thrombosed haemorrhoids
Strangulation of the haemorrhoids due to blood supply getting cut off

? DIAGNOSIS OF HAEMORRHOIDS
History and Physical Examination
Based on the patient’s history and symptoms, the clinician performs a digital rectal examination (DRE). During a DRE the surgeon inserts a gloved finger covered with lubricant jelly into the anal canal and examine for any swellings or other abnormalities that might be present. Based on findings further tests and referral to a surgeon may be advised to rule out other caused for rectal bleeding including colorectal cancer.

Proctoscopy
The interior of the anal canal and rectum are visualised using an instrument called proctoscope.

Colonoscopy
If felt appropriate, a colonoscopy examination may be performed to visualise the inside of the large bowel or colon. During this procedure, a thin flexible tube illuminated at one end is inserted into the anal opening and manoeuvred under visual control as far back as the caecum which is the initial part of the large bowel.

Colonoscopy will help to look for and identify other abnormalities of the large bowel that may be present such as polyps, diverticulosis or even cancer which may cause bleeding per rectum

TREATMENT OF HAEMORRHOIDS
? Medical treatment
Medical treatment of piles aims to relieve symptoms and include the following

o Fibre supplements in diet such as ispaghul, bran, methylcellulose or sterculia and stool softeners to ease passage of stools and prevent straining

o Special astringent ointments or suppositories advised by the doctor may reduce the swelling and shrink the haemorrhoids. Occasionally mild cases may resolve completely

o A soothing cream that contains an anaesthetic may offer pain relief. These should only be used for short periods at a time (5-7 days).

o A steroid cream may be recommended if there is lot of redness and inflammation in the anal region but these should again only be used for a short time (not more than a week)

o Ice packs to reduce swelling and discomfort

o Sitting in a warm tub (Sitz bath) of plain water for about 10 minutes especially after a bowel movement

? Non-Surgical Procedures
Various non-surgical options are available. These include

• Banding
Banding is the most commonly procedure to treat grade 2 and 3 piles. It may also be done for grade 1 piles which have not responded to simple conservative measures. This cuts off the blood supply to the piles which then dies and fall off in a few days. Most patients are cured by this method although it may occasionally recur

• Injection sclerotherapy
In this procedure, phenol in oil is injected at the base of the piles. This induces a scarring (fibrotic) reaction which blocks the blood supply of the piles. The piles then die and drop off, similar to what happens in banding

• Infrared coagulation/photocoagulation
In this method, infrared energy is used to burn and cut off blood supply to the haemorrhoid, which causes it to shrink in size. This procedure is as effective as banding and injection sclerotherapy for grade 1 and 2 haemorrhoids

• Diathermy and electrotherapy
This procedure heat energy to eradicate the piles. They seem to be as effective as infrared coagulation with low risk of any complications.

? Surgery
• Haemorrhoidectomy
This is a surgical procedure to remove grade 3 or 4 piles not cured by other procedures such as banding or sclerotherapy

• Haemorrhoidal artery ligation
The small vessels that supply the piles are tied (ligated), causing them to shrink.

• Stapled haemorrhoidopexy
A circular section of the lining of the anal canal above the piles is cut out using a stapling gun. As a result, the piles are drawn back in up the back passage. This procedure also reduces the blood supply to the piles and so they shrink as a consequence. It is less painful procedure than the traditional haemorrhoidectomy operation