Haemorrhoids (Piles) ✅

Related Subjects: |Rectal Prolapse |Anal Cancer |Anal Fissure |Perianal symptoms |Perianal abscesses and fistulae |Pilonidal Abscess (sinus) |Haemorrhoids (Piles) |Faecal Incontinence |Rectal Pain (Proctalgia) |Rectal Foreign Body |Acute Proctitis | Haemorrhoids (Piles)

🩸 Key sign: Haemorrhoidal bleeding is typically bright red, often seen on toilet paper, on the outside of the stool, or dripping into the pan. Pain is not typical of uncomplicated internal haemorrhoids; marked pain suggests thrombosis, prolapse/strangulation, fissure, abscess, or another diagnosis.

📖 About

• Haemorrhoids are normal vascular cushions in the anal canal; they help contribute to continence.
• Symptoms occur when these cushions become enlarged, bleed, prolapse, thrombose, or become inflamed.
• Internal haemorrhoids arise above the dentate line and are usually painless unless prolapsed/strangulated.
• External haemorrhoids arise below the dentate line and can be painful, especially if thrombosed.

⚠️ Risk Factors

• Constipation, straining, hard stools, prolonged time on the toilet.
• Low-fibre diet and inadequate fluid intake.
• Pregnancy and other causes of raised intra-abdominal pressure.
• Increasing age and weakening of supporting connective tissue.

🩺 Clinical Features

• Bright-red rectal bleeding, usually not mixed with stool.
• Anal swelling or prolapse during/after defaecation.
• Pruritus, mucus soiling, irritation, or a sensation of incomplete cleaning.
• Severe pain suggests thrombosed external haemorrhoid or another anorectal pathology rather than simple internal piles.

📊 Classification of internal haemorrhoids

• Grade I: bleed but do not prolapse.
• Grade II: prolapse with defaecation but reduce spontaneously.
• Grade III: prolapse and require manual reduction.
• Grade IV: irreducibly prolapsed.

🔍 Assessment

• Take a careful history of bleeding pattern, bowel habit, pain, weight loss, anaemia symptoms, family history, and colorectal cancer risk factors.
• Examine the perianal area and perform digital rectal examination if appropriate.
• Consider proctoscopy/anoscopy to confirm internal haemorrhoids if the diagnosis is uncertain or symptoms persist.
• Routine FBC/U&E/CRP are not needed for straightforward haemorrhoids; investigate further only if the history suggests anaemia, significant bleeding, infection, systemic illness, or an alternative diagnosis.

🚩 Red flags / when not to assume piles

• Persistent rectal bleeding, especially in older adults.
• Iron-deficiency anaemia.
• Change in bowel habit, weight loss, abdominal pain, or tenesmus.
• Palpable rectal or abdominal mass.
• Systemic symptoms or diagnostic uncertainty.

📌 NICE referral points

• Refer on a suspected cancer pathway for adults with a rectal mass.
• Refer on a suspected cancer pathway for adults aged 50 and over with unexplained rectal bleeding.
• Consider urgent referral for adults aged under 50 with rectal bleeding plus abdominal pain, change in bowel habit, weight loss, or iron-deficiency anaemia.
• For people without rectal bleeding but with unexplained lower GI symptoms who do not meet immediate referral criteria, NICE supports use of FIT to help guide colorectal cancer pathway referral.

💊 Management

• Conservative first-line: increase dietary fibre, fluids, avoid straining, treat constipation, and encourage good toilet habits.
• Use bulk-forming laxatives or stool-softening measures if needed to keep stools soft and easy to pass.
• Topical preparations may help short-term symptoms, but evidence is limited and they do not treat the underlying cause.
• Topical corticosteroid-containing products should be used only occasionally and short term (generally no more than 7 days).

🩹 Procedures

• Rubber band ligation (RBL): common office treatment for symptomatic grade I–II internal haemorrhoids, and selected grade III cases.
• Injection sclerotherapy: another outpatient option, especially for lower-grade bleeding haemorrhoids.
• Haemorrhoidal artery ligation / HALO: may be considered in selected patients.
• Haemorrhoidectomy: usually reserved for grade IV, mixed internal/external disease, or symptoms refractory to outpatient procedures.

🚑 Thrombosed external haemorrhoid

• Typically presents with sudden severe anal pain and a tender bluish perianal lump.
• Initial treatment is usually analgesia, stool-softening measures, and local care.
• If presentation is very early (for example within 72 hours) and pain is severe, urgent specialist assessment may be appropriate because excision can sometimes be considered.

⚠️ Complications

• Thrombosis.
• Prolapse and strangulation.
• Mucus leakage, irritation, and skin tags.
• Anaemia is possible with ongoing bleeding but is not typical of simple haemorrhoids and should prompt broader assessment.

🔄 Differentials

• Anal fissure.
• Perianal abscess or fistula.
• Rectal prolapse.
• Colorectal cancer or large polyps.
• Inflammatory bowel disease, proctitis, or infectious anorectal disease.

🌟 Teaching pearl: Painless bright-red bleeding suggests internal haemorrhoids, but rectal bleeding should never be dismissed without considering colorectal cancer. Pain points you away from simple internal piles and toward thrombosis, fissure, strangulation, or sepsis.

📚 References

• BNF/NICE Treatment Summary: Haemorrhoids
• NICE NG12: Suspected cancer – recognition and referral
• NICE HealthTech guidance: quantitative FIT to guide colorectal cancer pathway referral in primary care
• ACPGBI / ESCP Guideline for haemorrhoidal disease

Clinical Cases

• 🩸 Case 1 – Age 28: Painless bright-red bleeding on wiping, no weight loss, no altered bowel habit, no anaemia symptoms. Examination suggests small grade I internal haemorrhoids. Management: Fibre, fluids, bowel habit advice, short-term symptomatic treatment only. Teaching point: In younger low-risk patients with typical symptoms, conservative treatment is appropriate, but safety-net if bleeding persists.
• 💢 Case 2 – Age 46: Prolapsing tissue on defaecation requiring manual reduction, intermittent bleeding, no red-flag features. Management: Grade III internal haemorrhoids; discuss outpatient procedural treatment such as banding, while continuing bowel habit optimisation. Teaching point: Prolapse severity guides intervention more than bleeding alone.
• 🚑 Case 3 – Age 62: Severe pain with a tender bluish perianal lump. Management: Likely thrombosed external haemorrhoid; give analgesia and stool-softening advice, and consider urgent specialist review if onset is recent and pain is severe. Teaching point: Painful perianal swelling is not the classic presentation of internal piles.