Haemorrhoids (‘Piles’)
Definition
A submucosal swelling in the anal canal consisting of a dilated venous plexus, a small artery and areolar tissue. Internal: only involves tissue of upper anal canal above dentate line. External: involves tissue of lower anal canal below dentate line.
Aetiology
- Increased venous pressure from straining (low-fibre diet) or altered haemodynamics (e.g. during pregnancy) causes chronic dilation of submucosal venous plexus.
- Found at the 3 (left lateral), 7 (right anterior) and 11 (right posterior) o’clock positions in the anal canal.
Classification
- First degree: bulge into lumen but do not prolapse.
- Second degree: prolapse during defaecation with spontaneous reduction.
- Third degree: prolapse during defaecation and require manual reduction.
- Fourth degree: irreducible and may strangulate.
Clinical Features
- Bright red bleeding – on toilet tissue or staining toilet.
- Pruritus – may be leakage of rectal contents.
- Pain – associated with thrombosis.
- Prolapse – the haemorrhoid prolapses out of the anal canal.
- Thrombosis – very painful when in external haemorrhoid
Treatment
- 1st degree: bulk laxatives, high fluid and fibre diet.
- 2nd degree (some 3rd degree): rubber band (Barron’s) ligation, injection sclerotherapy, cryosurgery.
- 4th degree: haemorrhoidectomy (closed/open/stapled) (complications: bleeding, anal stenosis, pain). Haemorrhoidal artery ligation operation (HALO) – uses Doppler to identify haemorrhoidal artery which is then ligated – no need for general anaesthetic.
Rectal Prolapse
Definition
The protrusion from the anus to a variable degree of the rectal mucosa (partial) or rectal wall (full thickness).
Aetiology
Rectal intussusception, poor sphincter tone, chronic straining, pelvic floor injury.
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