Haemorrhoids (Piles)

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What is Haemorrhoids?

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Haemorrhoids or piles are located in the anus.

The term when used in a clinical sense, refers to the internal disruption or downward displacement of the anal cushions. The anal cushions are tissue structures rich in blood supply, that line the anus and contribute to anal closure.

They are classified according to their clinical presentation:

First degree haemorrhoids occur when the is some bleeding present.

Second degree heamorrhoids refer to spontaneously reducing prolapse of the anal cushions during defaecation.

Third degree haemorrhoids refers to prolapse requiring manual replacement.

Fourth degree haemorrhoids indicates permanent prolapse.

Haemorrhoids may be referred to as internal or external, depnding on the location of the prolapse.

Haemorrhoids are often defined as varicosity of the anal veins causing engorgement. This definition is incomplete, as although commonly defined through the clinical presentation of bleeding, haemorrhoids actually refer to the prolapse of the anal cushions.

Who gets Haemorrhoids?

Up to 4% of the population may have haemorrhoids. Many patients often do not present to health care facilities due to embarassment or the fact that the haemorrhoids spontaneously resolve.

The peak age of occurence is 45-65 years, however, they can occur at any age

Predisposing Factors

The anal cushion often prolapse due to engorgment of the blood vessels within them. Factors that mey predispose an individual to haemorrhoids may include: excessive straining on defecation, constipation, inflammatory bowel disease, pregnancy, colon cancer, liver disease, loss of muscle tone, occupational (prolonged sitting), obesity and chronic diarrhoea.

Progression

First and second degree internal haemorrhoids may present with rectal bleeding, a lump, discharge, or itching. They may not progress to third or fourth degree haemorrhoids, especially if the patient improves the fibre and fluid content of his/her diet.

Haemorrhoids may also present acutely with severe pain as they protrude through the anus and cause the anal sphincter to spasm. A positive "vicious cycle" can be responsible for progression of this episode. As the vascular cushions protrude through a tight anus, they become more congested, which may cause further protrusion, eventually causing the haemorrhoids to strangulate (cut off blood supply) - causing further severe pain and become difficult to be reduced. Eventually the haemorrhoids will ulcerate.

External haemorrhoids similarly may suddenly rupture - usually after straining at stool or heavy lifting. This usually causes thrombosis of the vein - and a painful swollen lump. The skin overlying the thrombosed vein can ulcerate - and eventually with healing a "skin tag" may be all that remains.

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