What are haemorrhoids and where do they occur?

They are caused by the engorgement of the internal haemorrhoidal venous plexus, which normally forms part of the anal cushions and may be internal (above the dentate line) or external (below the dentate line). They are normally found at 3, 7 and 11 o'clock in the lithotomy position.

What symptoms may be present?

Painless bleeding, discharge and irritation are common but large haemorrhoids may thrombose and infarct causing severe pain.

How are haemorrhoids classified?

1st degree These bleed but do not prolapse

2nd degree Prolapse on straining but reduce spontaneously

3rd degree Prolapse on straining and only reduce with manual assistance

4th degree Prolapsed and irreducible and may strangulate

Why should haemorrhoids be investigated?

Serious bowel pathology, for example a carcinoma or inflammatory bowel disease, must be excluded. Rectal examination, proctoscopy and sigmoidoscopy should therefore be performed in all cases.

What is the initial management of haemorrhoids?

Conservative treatments such as:

• Dietary advise (with increased fibre)

• Topical applicants

• Reduction of stool straining

• Laxatives if constipated

What treatment modalities are available in the outpatients department?

For 1st and 2nd degree haemorrhoids the following can be used:

• Injection sclerotherapy: About 23 ml of sclerosant (usually phenol in oil) is injected into the submucosal pedicle causing elevation of the submucosa and tissue necrosis.

• Rubber band ligation: During proctoscopy the haemorrhoid is identified and grasped using forceps. A band is applied at the base to strangulate the pile. This later sloughs off (this can also be used in 3rd degree haemorrhoids).