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• Affect 50% of population over the age of 50 years

• Usually presents with:

  • Painless bright red rectal bleeding

  • Prolapsing perianal lump

  • Acute pain due to thrombosis

  • Faecal soiling or pruritus ani

Pathogenesis

• The following factors appear important:

  • Dilatation of venous plexus

  • Distension of AV anastomoses

  • Displacement of anal cushions

• 80% of patients have high resting anal pressure

Classification

• Haemorrhoids are often classified as internal or external

• Internal haemorrhoids arise above the dentate line and can be sub-classified as

  • First degree - bleeding only

  • Second degree - prolapse, reduce spontaneously

  • Third degree - prolapse, pushed back

  • Fourth degree - permanently prolapsed

Picture provided by J M Enriques-Navascies, Hospital Donostia, San Sebastian, Spain.

Picture provided by Michael Rudd, Royal Brisbane Hospital, Brisbane, Australia

Treatment

• All should have high residue diet

• Local preparations rarely produced long-term clinical benefit

Outpatient

• Treatment options for first and second degree haemorrhoids include:

  • Injection with 5% phenol in arachis or almond oil

  • Rubber band ligation

• Randomised trial of rubber band ligation and sclerotherapy have shown

• 90% success with rubber band ligation

• 70% success with sclerotherapy

Inpatient

• Treatment options include:

  • Dilatation and banding

  • Haemorrhoidectomy

• Haemorrhoidectomy is usually performed as an open procedure (Milligan-Morgan)

• It is the treatment of choice for third-degree haemorrhoids

• Secondary infection and postoperative pain may be reduced with oral metronidazole

• Botulinum toxin injection may also reduce postoperative pain

• Complications include bleeding (3%), urinary retention (10%)

• Anal stenosis may develop adequate skin bridges are not maintained

• Other haemorrhoidectomy techniques include closed or stapled procedures

• The recently described stapled technique is associated with:

  • Reduced operating time

  • Less postoperative pain

  • Shorten hospital stay

  • More rapid return to normal activity

Pictures provided by Reda Saad, El Demerdash University Hospital, Cairo, Egypt

Bibliography

Brisinda G.  How to treat haemorrhoids.  Br Med J 2000:  321:  582-583.

Carapeti E A,  Kamm M A,  McDonald P J et al.  Double-blind randomised controlled trial of effect of metronidazole on pain after day-case haemorrhoidectomy.  Lancet 1998;  351:  169-172.

Davies J,  Duffy D,  Boyt N et al.  Botulinum toxin reduces pain after haemorrhoidectomy:  results of a double-blind, randomized trial.  Dis Colon Rectum 2003;  46:  1097-1102.

Fazio V W.  Early promise of stapling techniques for haemorrhoidectomy.  Lancet 2000;  355:  768-769.

Loder P B,  Philips R K S.  Haemorrhoidectomy.  Curr Pract Surg 1993; 5: 29 - 35.

Loder P B.  Haemorrhoids: pathology, pathophysiology and aetiology.  Br J Surg 1994: 81; 946 -954.

Mehigan B J,  Monson J R T,  Hartley J E.  Stapling procedures for haemorrhoids versus Milligan-Morgan haemorrhoidectomy:  randomised controlled trial.  Lancet 2000;  355:  782-785.

Roswell M,  Bello M,  Hemmingway D M.  Circumferential mucosectomy (staple haemorrhoidectomy) versus conventional haemorrhoidectomy :  randomised controlled trail.  Lancet 2000;  355:  779-781.

Shalaby R,  Desoky A.  Randomised clinical trial of stapled versus Milligan-Morgan haemorrhoidectomy.  Br J Surg 2001;  88:  1049-1053.

Shanmugam V,  Thaha M A,  Rabindranath K S.  Systematic review of randomized trials comparing rubber band ligation with excisional haemorrhoidectomy.  B J Surg 2005;  92:  1481-1487.

Sutherland L M,  Burchard A K,  Matsuda K et al. A systematic review of stapled hemorrhoidectomy. Arch Surg 2002;  137:  1395-1406

Last updated: 05 January 2008

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