Haemorrhoids

Haemorrhoids are part of normal anatomy. This topic refers to symptomatic haemorrhoids, which occurs with enlargement and/or protrusion of the haemorrhoidal cushion.

Risk factors

• Prolonged sitting and straining
• Chronic constipation
• Other less important factors:
  • Age
  • Diarrhoea
  • Pregnancy
  • Pelvic tumours
  • Anticoagulation/antiplatelets (may not be causal)
• There may be an aetiological relationship between the presence of a portosystemic shunt at the superior haemorrhoidal veins, and development of actual symptomatic haemorrhoids, but it is uncertain. Some patients do develop true varices within the anorectal mucosa.

Pathophysiology

• Not simply varices of haemorrhoidal veins, but dilated cushions of arteriovenous tissue. These cushions lie in submucosa and comprise dilated blood vessels, smooth muscle and connective tissue, at 4, 7, and 11 o'clock positions, at or above the level of the anal valves.
• Increased intra-anal pressure leads to abnormal dilatation and engorgement of vascular channels
• An inflammatory reaction and vascular hyperplasia may be evident
• Deterioration of connective tissue that anchors haemorrhoids, starting as early as young adulthood, allowing the cushions to become displaced distally
• Can lead to bleeding, thrombosis and/or tissue prolapse

Presentation

• Most commonly painless bright red bleeding with bowel movements, and sometimes a lump
• Key factors are the extent, severity and duration of symptoms; issues of perineal hygiene; and presence or absence of pain
• Discuss fibre intake and bowel habits
• Anorectal examination to evaluate the extent of haemorrhoidal disease and search for other abnormalities

Strangulated internal haemorrhoid (sometimes called thrombosed)

• • Irreducible haemorrhoids, but shouldn't cause too much pain due to less somatic innervation. Still sometimes can cause pain with necrosis.
  • Can become necrotic and bloody
  • If no necrosis, attempt manual reduction and treat with sitz baths, ice and analgaesia; but better not to attempt reduction if there is necrosis
  • High-risk for stricture formation to do a haemorrhoidectomy in this setting, therefore most surgeons won't do it. If you are operating, be very careful with tissue planes, internal sphincter preservation, and haemostasis. Preserve as much anoderm and mucosa as possible, to prevent stricture formation.
  • Ideally, manage conservatively until fully settled, then offer haemorrhoidectomy
  • Those with incarceration, strangulation and necrosis should have a haemorrhoidectomy

Thrombosed external haemorrhoid

• • Lots of variation in semantics, but many say this is the same entity as a perianal haematoma - others differentiate between the two and call a perianal haematoma an extravascular haematoma which gives a more circular lump, probably with a skin bridge, NOT mucosa
  • Acute severe pain, exacerbated by sitting or defecation, which may be preceded by an episode of constipation or diarrhoea
  • Can sometimes be complicated by necrosis, which should usually have some sort of external manifestation - surrounding cellulitis or systemic features
  • Usually associated with internal haemorrhoids too, but those usually remain soft because the thrombosis is in the superficial channels
  • Usually resolves within 72 hours
  • Trial sitz baths, topical lignocaine and stool softeners
  • Surgery for severe pain or significant bleeding - excise the thrombosed haemorrhoid but leave the rest alone

Acute bleeding

• • Haemorrhoidectomy is generally favoured to banding, as bleeding can be worsened when the band sloughs off, especially if the patient is anticoagulated
  • If can't stop anticoagulation for 7-14 days, better off with formal haemorrhoidectomy

Internal vs external

• Internal haemorrhoids arise from superior haemorrhoidal cushion, above dentate line. Covered by anoderm. Insensate - overlying epithelium is viscerally innervated.
• External haemorrhoids from inferior haemorrhoidal plexus, below dentate line. Covered by skin, and therefore have sensation.
• Internal and external haemorrhoids communicate with one another, and are probably caused by the same antecedent factors
• There is probably no particular relationship between internal haemorrhoids and portal hypertension

Grading internal haemorrhoids:

• Grade 1: bulge, but no not prolapse below dentate line
• Grade 2: prolapse with straining but reduce spontaneously
• Grade 3: prolapse and require manual reduction
• Grade 4: can't be reduced

Management

Lifestyle measures: (low risk, worth trying to see if it helps, then move on to intervention if not)

• • Stool texture - high-fibre diet and supplementation; stool softeners - movicol; stay hydrated
  • Topical LA or steroid-based suppositories for pain (proctosedyl 30g tube contains steroid and LA)
  • Stool habits - avoid straining and limit time on toilet, use a footstool to improve puborectalis sling angle
  • Hygiene - sitz bath or shower after defecation

Office-based therapy

• • Indication - grade I, II or III internal haemorrhoids refractory to 8 weeks of conservative management
  • Options:
    • RBL (proven to be best and easiest)
      • Strangulates haemorrhoidal tissue, leading to ischaemia and necrosis of the prolapsing mucosa, followed by scar fixation to the rectal wall. Resolves symptoms by decreasing the size of the haemorrhoidal tissue and fixes it to the wall.
      • Place band 2cm above dentate line
      • >90% success rate
      • Best to band only one haemorrhoid at initial session
      • Band sloughs off in a week, which can cause bleeding, especially for those on anticoagulation. Fletcher says do not band unless you can withhold anticoagulation for two weeks.
      • Complications
        • Aside from the usual pain, bleeding
        • Can cause thrombosis of adjacent external haemorrhoid
        • Severe pain immediately after placement = placed too close to dentate line
        • Pelvic sepsis can develop - fever, severe pain, retention, requiring debridement of necrotic tissue
    • Sclerotherapy
      • Sclerosant injected to haemorrhoid (e.g. 5% phenol in 5ml almond or vegetable oil, hypertonic salt solution, or ethanolamine) which results in fibrosis and fixation of the haemorrhoid to the bowel wall
      • Inject 1cm above dentate line into submucosa of each haemorrhoid, at the apex of the haemorrhoid
      • For phenol, inject 1-3mL into each haemorrhoid (Sabiston says 1mL per haemorrhoid)
      • Don't need to stop anticoagulation
      • If needle site bleeding - manual pressure, should stop easily
      • Long-term inferior to RBL, but useful in anticoagulated patients or those immunocompromised (lower risk of sepsis)
    • Infra-red coagulation
      • Direct application of infra-red light, resulting in protein coagulation within the haemorrhoid
      • Typically need 3-4 applications for each haemorrhoid
      • Infra-red energy results in thrombosis and tissue destruction, leading to scarring and fibrosis
      • More expensive and less effective than RBL
      • Best for patients on anticoagulants
      • Best for grade 1 and 2 haemorrhoids

Formal haemorrhoidectomy

• • Indications
    • Grade IV internal
    • Grade I, II or III internal in the presence of other anorectal disease, including substantial skin tags
    • Internal with failure of office-based therapy
    • Symptomatic external haemorrhoids refractory to medical treatment and office-based treatment (not required very often)
    • Consider haemorrhoidectomy for thrombosed haemorrhoids within 72 hours of initial pain
      • Best to formally excise - 5-19% recurrence rate compared with 30% recurrence rate for simple incision
      • Conservative management first, as there is some evidence that there is a higher incidence of sphincter injury when haemorrhoidectomy is done electively
  • Technique
    • See separate topic