Haemorrhoids

Introduction

Haemorrhoids, also called piles, are swollen veins develop inside the rectum (internal haemorrhoids) or under the skin around the anus (external haemorrhoids).

Haemorrhoids can occur at any age but are rare in children and adults younger than 20 years. There is a high incidence of haemorrhoids in pregnant women.

Symptoms

Symptoms experienced by the patient are dependent on the severity or type of haemorrhoid.

• Bright red painless rectal bleeding is the most common symptoms.
• Blood is usually seen as spotting around the toilet, streaking on toilet tissue or visible on the surface of the stool.
• Internal haemorrhoids are rarely painful, whereas external haemorrhoids can cause pain due to the cushion becoming thrombosed.
• Pain is not always present. If it is, the pain is described as a dull ache that increases in severity when the patient defecates, leading to patients ignoring the urge to defecate. This can then lead to constipation, which in turn will lead to more difficulty in passing stools and further increase the pain associated with the defecation. NOTE: A severe sharp pain on defecation may indicate anal fissure.
• Itching and irritation are also commonly observed.
• Symptoms are often intermittent, and each episode usually lasts from a few days to few weeks.

Indicative of Referral

Severe (e.g. prolapsing haemorrhoid) or persistent (>3 weeks) cases

• May need surgical intervention, such as rubber ligation, sclerotherapy injections and haemorrhoidectomy.

Severe pain associated with defecation

• Anal fissure?

Blood mixed in the stool

• Suggests GI bleeds or inflammatory bowel disease.

Management

General measures to prevent constipation will help decrease straining during defecation, ease the symptoms of haemorrhoids and reduce recurrence.

• Eat high-fiber foods, e.g. fruit, vegetables, bran and whole-grain bread
• Drink plenty of fluids
• Exercise
• Consider fiber supplements or laxatives (if needed)

Pharmacological intervention - Most products contain a combination of these agents, e.g. Xyloproct and Proctosedyl.

• Local anaesthetics (e.g. benzocaine, lidocaine, cinchocaine)
• Their action is short-lived (require frequent application) and will produce temporary relief from perianal itching and pain.
• There is a possibility that local anaesthetics may cause sensitisation, and their use is best limited to a maximum of 2 weeks.
• Astringents (e.g. allantoin, bismuth, zinc, Peru balsam)
• Theoretically, they precipitate surface proteins, thus producing a protective coat over the haemorrhoid.
• Topical steroids (e.g. hydrocortisone)
• Steroid have proven effectiveness in reducing inflammation.
• The use of such products is restricted to those over 18 and treatment should not be used continuously for longer than 7 days.
• Topical corticosteroids may exacerbate local infection and cause skin atrophy.
• Flavonoids
• Dietary supplementation with flavonoids is a common alternative treatment that is popular in continental Europe and the Far East.
• As an adjunct, their use has been shown to reduce acute symptoms and secondary haemorrhage after haemorrhoidectomy.

External Links

• Comparative efficacy and tolerability of two ointment and suppository preparations ('Uniroid' and 'Proctosedyl') in the treatment of second degree haemorrhoids in general practice, 1988
  
• Fiber for the treatment of haemorrhoids complications: a systematic review and meta-analysis, 2006
  
• Meta-analysis of flavonoids for the treatment of haemorrhoids, 2006
  
• Counselling Patients With Haemorrhoids, 2011