- Haemorrhoids (Rectal varices) always start as internal with time become interoexternal in respect of anal orifice.
- Classified as first degree, if they project into the anal canal and do not prolapse outside it; second degree, if they prolapse out of the anus but return spontaneously or digitally; and third degree, if they remain out all the time.
- ‘Symptomatic’ Haemorrhoids are due to other conditions such as, carcinoma of rectum, pregnancy, straining at micturition, or straining at chronic constipation.
- Haemorrhoids become important when they start bleeding.
- Hereditary. May be, as common in families.
- Exciting causes. No doubt undue straining habits, or straining at constipation or at irritation of the anum due to nature of diet (spice food), or at micturition is considered to be a potent cause of haemorrhoids.
- Co-exiting causes may be rectal cancer, enlarged prostate, stricture of urethra, pregnancy, pelvic tumours, and rarely, portal hypertension.
- Straining causes anal cushions (which are necessary for full continence) to slide downwards, and internal haemorrhoids develop in the prolapsing tissues.
- Primary haemorrhoids are commonly located at 3, 7, and 11 o’clock in lithotomy position according to haemorrhoidal artery division (but not always) and in between them may be small secondary haemorrhoids.
- Each principal haemorrhoid can be divided into three parts, the pedicle is situated at the anorectal ring covered with pale pink mucosa, The internal haemorrhoid, which commences just below the anorectal ring, it is bright red or purple, covered by mucous membrane and of variable size, An external associated haemorrhoid lies between the dentate line and the anal margin, it is covered by skin, through which blue veins can be seen.
- Entering into the pedicle of an internal haemorrhoid may be a branch of the superior rectal artery, very occasionally there is a haemangiomatous condition of this artery -an ‘arterial pile’ – which leads to ferocious bleeding at operation.
Presentation / Symptoms
- Bleeding, Painless bright red bleeding in the form of drops or a jet is the principal and earliest symptom, aggravated by straining and may continue intermittently for months or years.
- Haemorrhoids that bleed but do not prolapse outside the anal canal are called first-degree haemorrhoids.
- Prolapse is a later symptom, in the beginning it is slight and occurs only at stool, and reduce spontaneously or manually called second-degree while permanently prolapsed are called third-degree haemorrhoids.
- Discharge. A mucoid discharge is frequent in prolapsed haemorrhoids.
- Pruritus almost certainly follow this discharge.
- Pain is absent unless complications supervene, for this reason, any patient complaining of ‘painful piles’ must be suspected of having another condition (possibly serious) and examined accordingly.
- Anaemia can be caused by persistent bleeding from haemorrhoids.
- On inspection there may be no evidence of first degree internal haemorrhoids, second-degree haemorrhoids come into view transiently on straining and third degree are permanently visible.
- Digital examination. Internal haemorrhoids cannot be felt unless they are thrombosed.
- Proctoscopy. First- and second-degree piles are visualized on proctoscopy as they protrude into its lumen.
- Sigmoidoscopy. Should be done if suspecting sigmoid colon pathology.
- Amoebic proctitis, ulcerative colitis, rectal polyp, mucosal prolapse, and cancer of the rectum are the differential diagnosis.