Haemorrhoids

Anal continence requires the apposition of three mucosal pads which:

• are composed of subepithelial vascular cushions
• are found in the left lateral, right anterolateral and right posterolateral portions of the anal canal
• form haemorrhoids when the pads become enlarged and congested

Hemorrhoids are classified as:

• internal
• external
• mixed (concurrent internal and external hemorrhoidal disease)

Internal hemorrhoids originate above the dentate line(the boundary between the upper and lower anal canal) and may cause:

• rectal bleeding
• discomfort
• tissue prolapse from the anal canal

Internal hemorrhoid prolapse is classified as:

• grade I (into anal canal)
• grade II (beyond the anus with spontaneous reduction)
• grade III (requiring manual reduction)
• grade IV (irreducible)

External hemorrhoids, arising below the dentate line, cause rectal pain when engorged or thrombosed.

Management principles:

• initial treatment of all hemorrhoidal disease involves
  • increasing intake of dietary fiber and water
  • avoiding straining during defecation
  • phlebotonics (eg, flavonoids [are believed to improve venous tone]) reduce bleeding, rectal pain, and swelling
    • note though that symptom recurrence reaches 80% within 3 to 6 months after treatment cessation
• If dietary modification and phlebotonics are ineffective, grade I to grade III internal hemorrhoidal disease can be treated with outpatient-based interventions
  • rubber band ligation resolves symptoms in 89% of patients, but repeated banding is needed in up to 20%
  • sclerotherapy
    • induces fibrosis with a sclerosant injection
    • efficacious in the short term (weeks to months) among 70% to 85% of patients, but long-term remission occurs in only one-third of patients
  • infrared coagulation
    • uses heat to coagulate hemorrhoidal tissue
    • results in 70% to 80% success in reducing bleeding and prolapse
• surgical procedures:
  • excisional hemorrhoidectomy
    • for disease unresponsive to outpatient-based therapy or for mixed hemorrhoidal disease
    • achieves low recurrence (2%-10%), although with longer recovery (9-14 days)

Notes:

• external hemorrhoidal disease
  • rarely requires surgery unless acutely thrombosed
  • outpatient clot evacuation within 72 hours of onset of a thrombosed external hemorrhoid is associated with decreased pain and reduced risk of repeat thrombosis
  • patients presenting more than 72 hours after external hemorrhoid acute thrombosis should receive medical treatment (eg, stool softeners, oral and topical analgesics such as 5% lidocaine) (2)

Reference

1. Acheson AG, Scholefield JH; Management of haemorrhoids. BMJ. 2008 Feb 16;336(7640):380-3.
2. Ashburn JH. Hemorrhoidal Disease: A Review. JAMA. 2025;334(17):1541–1550.