Haemorrhoids

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Haemorrhoids or “piles” are enlarged, displaced anal cushions derived from engorged veins, which primarily presents with anal bleeding. First-degree haemorrhoids remain in the anal canal. Second-degree haemorrhoids prolapse, but reduce spontaneously, whereas third degree haemorrhoids prolapse and have to be replaced manually or remain prolapsed permanently until surgically treated.

The history is very important. The nature of the bleeding, associated pain and other symptoms help differentiate haemorrhoids from other more sinister conditions. Always do a digital rectal examination to exclude carcinoma and other conditions when a patient complains of pain or bleeding from the anus. Altered or dark blood, or blood mixed with stools, should raise suspicion of bleeding higher up in the rectum or colon.

No treatment is required for haemorrhoids that are asymptomatic.

Avoid the use of purgatives.

Cause

  • Increased intra-abdominal pressure e.g. chronic cough, pregnancy, intra-abdominal or pelvic tumours
  • Excessive straining at stools from constipation or diarrhoea
  • Familial predisposition
  • Chronic liver disease with portal hypertension
  • Anorectal tumours

Symptoms

  • Passage of bright red blood at defaecation
  • Not mixed with stools
  • May spray the toilet bowl or only found on the toilet paper after cleaning
  • Mucoid discharge
  • Swelling at anus
  • Perianal irritation or itch (pruritus ani)
  • Discomfort after opening bowels
  • Anal pain (occurs during an acute attack of prolapse with thrombosis, congestion and oedema)
  • Symptoms of anaemia

Signs

  • May be none (inspection of the anus and digital rectal examination may be normal)
  • Redundant folds of skin (skin tags) seen in the position of the haemorrhoids. Straining may show the haemorrhoids
  • Swelling at the anus (in third degree haemorrhoids)
  • Palpable thrombosed internal haemorrhoids on rectal examination
  • Signs of complications (profuse bleeding with anaemia or haemorrhagic shock, prolapse, strangulation, thrombosis, infection
  • or ulceration)
  • Pallor       

Investigations

  • FBC
  • Proctoscopy (the gold standard for diagnosis)
  • Sigmoidoscopy (to exclude carcinoma of rectum)

TreatmentTreatment Objectives

  • Treatment objectives
  • To correct anaemia, if present
  • To relieve symptoms
  • To prevent complications

Non-pharmacological treatment

  • Increase intake of fluid and roughage
  • Avoid prolonged straining at defecation
  • For prolapsed haemorrhoids, lie patient down and elevate the foot end of the bed. Try gentle digital reduction after application of local anaesthetic cream. If this fails, apply cold compresses. Sedation of the patient may be required
  • For infected haemorrhoids, warm sitz baths 2-3 times a day
  • Surgical treatment:
    • Rubber band ligation for second-degree haemorrhoids.
    • Haemorrhoidectomy for third degree haemorrhoids.
    • Haemorrhoids developing during pregnancy should be managed conservatively as most will resolve after delivery

Pharmacological Treatment

When associated with constipation

Evidence Rating: [C]

  • Liquid paraffin, oral,

Adults 10-30 ml at night

Or

  • Senna granules, oral,

Adults 1 sachet with water after supper

When associated with local itching or discomfort

  • Soothing agent (with or without steroids), applied or inserted rectally,

Adults

One suppository 12 hourly for 7-10 days

For infected haemorrhoids

1st Line treatment

Evidence Rating: [B]

  • Gentamicin, IV,

Adults

40-80 mg 8 hourly for 5 to 7 days

And

  • Metronidazole, oral,

Adults 400 mg 8 hourly for 5 to 7 days

2nd Line treatment

Evidence Rating: [B] 

  • Ciprofloxacin, oral,

Adults 500 mg 12 hourly

And

  • Metronidazole, oral,

Adults

400 mg 8 hourly for 5 - 7 days

3rd Line treatment

Evidence Rating: [B]

  • Amoxicillin, oral,

Adults

500 mg 8 hourly

And

  • Metronidazole, oral,

Adults

400 mg 8 hourly for 5 to 7 days

When associated with anaemia

  • Iron preparation (ferrous sulphate/fumarate) (See full Ghana STG section on ‘Anaemia’)

Or

Blood transfusion as indicated

Referral Criteria

The patient should be referred to a facility with resources for rubber band ligation or operative treatment if indicated.