The basics - Management of haemorrhoids

Internal and external haemorrhoids will usually present differently, explains Dr Tillmann Jacobi.

External haemorrhoids always feature a prolapse which is typically very painful (Photograph: SPL)

Haemorrhoids are enlarged or changed tissue in the lower rectal and anal area. Usually both connective tissue and vascular elements are involved, which explains why haemorrhoids can lead to local discomfort and bleeding.

Haemorrhoids can be classified as external haemorrhoids and internal haemorrhoids. There are four different degrees depending on if they are prolapsing and if a reduction is possible or not.

Anatomically, the difference is determined by the dentate line, which may help classification, but does not have a particularly practical significance.

Haemorrhoids can also be distinguished in terms of their occurrence as an isolated problem, intermittent-episodic or chronic. The majority of adults in the western world experience some haemorrhoidal symptoms at some point during their life, but only few will require medical help.

1. Risk factors
Haemorrhoids are uncommon in children but a frequent problem in adults with an almost equal distribution among men and women. Risk factors include pregnancy or other causes of increased intra-abdominal pressure, suboptimal diet with low fibre intake and increased risk of constipation or straining or even chronic-intermittent diarrhoea.

A strong family history will also increase the likelihood of haemorrhoids.

2. Clinical presentation
Internal and external haemorrhoids usually present differently. Internal haemorrhoids tend to cause painless bright-red bleeding, which is on the faeces but not mixed in. There can be local itching, soiling and blood on the toilet paper. In more advanced stages patients may notice a prolapse.

External haemorrhoids always feature a prolapse, which is typically very painful because of thrombosis and a resulting perianal haematoma. Bleeding is not always present unless the enlarged blood vessels tear or erode.

3. Assessment and diagnosis
When taking the history it is important to enquire about changes of bowel habit, type and duration of pain, significant family history, weight changes or fatigue and the colour and distribution of bleeding.

Changes to the diet, recent travels abroad and current occupation should be noted.

The physical examination includes the abdomen as well as the anal area with digital rectal examination if this is not too painful. Note that haemorrhoids may empty with the pressure from the examination and therefore can appear much smaller than they actually are.

Important differential diagnoses of haemorrhoids include colorectal or anal cancer, inflammatory bowel disease (ulcerative colitis and Crohn's disease) and diverticular disease. Sometimes anal fissures, fistulas, warts or ulcers and polyps are the cause for the anal discomfort. Also, local infection or inflammation (thread worms, contact dermatitis) can resemble the symptoms of haemorrhoids.

4. Management
Management will be determined by the clinical findings, the severity and duration of symptoms and the risk of any potentially serious differential diagnosis.

Investigations in primary care may include proctoscopy or rigid sigmoidoscopy, testing for faecal occult blood and baseline bloods, especially to exclude iron deficiency anaemia. Barium enemas have limited value regarding detail of results and, in addition to the inconvenience, they expose the patient to a large dose of radiation.

Patients may require a referral for flexible sigmoidoscopy or colonoscopy. CT or MRI may be required in the event of any abnormal findings, advancing age (more than 50 years) and a significant family history of colorectal cancer.

Cases with severe pain, third or fourth degree internal haemorrhoids (not easily reducible) and patients with a possible systemic condition, such as inflammatory bowel disease, should be referred regardless of age.

The patient should be given information about the possible treatment options (injection sclerotherapy, infrared coagulation or other topical treatments, rubber band ligation and haemorrhoidectomy),which will be chosen depending on the severity. The outcomes can vary quite considerably.

If the haemorrhoids are caused by pregnancy they are likely to resolve after delivery.

Conservative treatment of haemorrhoids with topical ointments and suppositories are generally safe and useful in most mild to moderate cases.

However, long-term use of local anaesthetics or steroids should be discouraged. Nitroglycerine ointments are often effective (although they are unlicensed for this purpose). These should be used carefully in children or the elderly because of an increased risk of side-effects.

External haemorrhoids, which cause mild to moderate pain, can be managed conservatively using topical treatments and cold compresses and typically resolve within 10 days.

If the pain is severe and the patient presents within 72 hours of onset, a referral for incision and drainage of the thrombosed haemorrhoid can be beneficial.

If the patient presents later than 72 hours after onset, conservative treatment is preferable. In patients with chronically increased anal sphincter tone some stretch procedures can be effective.

Patients should be advised that recurring symptomatic haemorrhoids can be prevented through increasing fibre intake.

However, a sudden increase of fibre intake can cause considerable bloating and bowel upset and may not be appropriate for all patients.

Taking fibre-based laxatives might be more feasible and is generally quite effective.

Key Points
  • Haemorrhoids are a frequent problem in developed countries due to lifestyle and diet.
  • Mild to moderate cases of both internal and external haemorrhoids usually respond well to conservative treatment.
  • A detailed history and appropriate examination is essential to decide on the need for further investigations.
  • Prevention of recurrence is an important part of management.
  • Surgical treatments have variable outcomes.
  • Dr Jacobi is a GP partner in York.

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