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Chapter: Medicine and surgery: Gastrointestinal system

Haemorrhoids (piles) - Disorders of the rectum and anus

Enlarged and engorged veins in or around the anus. - Definition, Incidence, Aetiology, Pathophysiology, Clinical features, Complications, Investigations, Management, Prognosis.

Disorders of the rectum and anus

Haemorrhoids (piles)




Enlarged and engorged veins in or around the anus.





Associated with constipation and straining to pass stool or during labour. Suggested that low fibre Western diet accounts for increased incidence.





It is thought that increased abdominal pressure causes dilatation of the internal haemorrhoidal plexus of blood vessels. These drain to the portal system and contain no valves.


·        First degree piles bulge into the lumen without prolapsing through the anus.


·        Second degree piles prolapse on defecation but return spontaneously.


·        Third degree piles remain prolapsed but can be actively returned.


·        Fourth degree piles are those that can not be returned to the anal canal. The anal sphincter contracts around a prolapsed haemorrhoid causing venous congestion and a risk of thrombosis.



Clinical features


Patients normally present with rectal bleeding which is typically a bright red streak on the toilet paper. Severe bleeding may cause blood in the toilet. Prolapse may be noted and cause a mucus discharge. Pain occurs with strangulated or thrombosed piles.





Proctoscopy visualises the piles, prolapse is demonstrated on straining. Flexible sigmoidoscopy is essential in cases of rectal bleeding to exclude other pathology and a barium enema or colonoscopy may be indicated depending on the index of suspicion of inflammatory bowel disease or malignancy.




Small asymptomatic piles are managed conservatively, a high-fibre diet may reduce constipation. First-degree piles can be treated by sclerosing injection into the pedicle. More severe haemorrhoids may be treated by following:


·        Ligation: The pile is pulled down through a proctoscope and a rubber band is applied to the pedicle. One pile is treated at a time with intervals of 3 weeks between treatments.


·        Infrared photocoagulation causes necrosis within the haemorrhoid and hence shrinkage.


·        Haemorrhoidectomy requires ligation and excision. Postoperative pain is common especially on defecation. Complications include haemorrhage and rarely anal stenosis, abscesses, fissures or fistulas.

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