Haemorrhoids

Question 1

What are haemorrhoids?

Answer 1

swellings that develop inside and around the anal canal (last part of the large intestine)

Question 2

What are the classifications of haemorrhoids? How can they identified?

Answer 2

internal (upper part of anal canal)

• 2-3cm inside anus
• often painless (upper canal has no pain nerve fibres)

external (lower part of anal canal)
- painful (lots of pain nerve fibres in end of anus)

proctoscopy
- small hollow tube with light at one end, allows GP to see whole of back passage

Question 3

What are the types of haemorrhoids (piles)?

Answer 3

are classified according to four grades according to severity and size

Grade 1 - most common

• small swelling inside anal canal
• can enlarge and go to grade 2

Grade 2
- partial prolapse
= can push out when you go to toilet but they spring back in

Grade 3
- prolapse from the anus
= hang out of anus when you go to the toilet but can be pushed back in with finger

Grade 4
- permanent prolapse from anus
= unable to be pushed back in

larger piles often have mucous discharge, pain, irritation and itching

Question 4

What are the causes of haemorrhoids?

Answer 4

constipation
prolonged straining
- puts increased pressure on veins around anus

ageing (increased prevalence)
- loss of tissue elasticity

hereditary factors
- inherited weakness in vein walls of the anal canal

pregnancy

• increasing uterus size causes increased pressure on anal canal
• hormones also dilate veins

Question 5

What should be asked when talking to patients about piles?

Answer 5

who
what are the symptoms
- pain on passing, blood (bright red or dark, on topper mixed with stools), abdominal pains, bloating

how long
- if over 3 weeks and not responding to OTC then refer

wha actions have been taken
any other medication

Question 6

What are symptoms of haemorrhoids?

Answer 6

bleeding on defecation
pain and discomfort
pruritus/tender lumps around anus
- itching around the anus

mucous discharge
- more common with larger piles

feeling of incomplete defecation
partial incontinence

Question 7

When should patients with haemorrhoids be referred?

Answer 7

not responding to OTC
longer than 3 weeks

excessive bleeding, accompanied by change in bowel habit/weight loss

blood in stools
- mixed with stools rather than surface is a sign of colorectal cancer

Question 8

What are differential diagnosis for haemorrhoids?

Answer 8

anal fissure
- intense pain on passing, blood will be bright red

ulcerative colitis or crohn’s disease
- watery, loose, bloody stools associated with fever, abdominal pains

lower GI bleed
colorectal cancer

IBS
- bloating, tender stomach, triggered by certain food types
threadworm
- itching at night when eggs laid in anal canal

Question 9

What are lifestyle measures that can be taken to treat haemorrhoids?

Answer 9

increase dietary fibre
- wholegrains, fruit, vegetables

increase fluid intake
- 2 litres, avoid caffeinated drinks

good hygiene
- keep area clean and free from irritating faecal matter, use moist toilet wipes

avoid straining
- do not delay going to the toilet

warm baths
application of cold compress onto pile to shrink via vasoconstriction

suitable pain relief
- avoid codeine and other opioid based painkillers

Question 10

What are pharmacological treatments for haemorrhoids?

Answer 10

topical preparations
- Zinc Oxide, Balsam of Peru, Allatoin

local anaesthetics
- lidocaine/cinchocaine/benzocaine

topical corticosteroids
- hydrocortisone/zinc oxide

astringent agents
- Bismuth Oxide, Witch Hazel

Question 11

How do topical preparations work? What are the different types and their effects?

Answer 11

Zinc Oxide - Anusol
- regeneration/healing around the area
Balsam of Peru and Allatoin
- cooling effect

mode of action:

• possess emollient and protective properties
• prevent local irritation

available as creams, ointments, suppositories and sprays

Question 12

How do local anaesthetics work? What are the different types and their effects?

Answer 12

lidocaine/cinchocaine/benzocaine

mode of action:

• alleviates pain, burning and itching
• may cause sensitisation of perianal skin
• maximum usage is 5 days

Question 13

How do topical corticosteroids work? What are the different types and their effects?

Answer 13

hydrocortisone/zinc oxide

mode of action:

• reduces inflammation
• alleviates pain
• maximum usage is 7 days

Question 14

How do astringent agents work? What are the different types and their effects?

Answer 14

Bismuth Oxide, Witch Hazel

mode of action:
upon application, proteins are precipitated on skin
- forms a protective layer
- relieves irritation and inflammation

Question 15

What are secondary care treatments? What are they used for?

Answer 15

1. Rubber Band Ligation
   - apply band to base of haemorrhoid = strangulation
   - pile becomes necrotic and sloughs off
2. Injection Sclerotherapy
   - phenol oil is injected into submucosa of rectum which irritates it causing collapse inducing fibrotic reaction
   - obliterates the haemorrhoid vessels, resulting in atrophy of haemorrhoid
3. Surgery
   - haemorrhoidectomy
   - stapled haemorrhoidectomy
   = staple gun is used to push haemorrhoid back inside anal canal and is fastened to the area using staples.
   = surgical intervention is for Grade 3-4