Discuss the pathogenesis of haemorrhoids?

There is a plexus of veins (also called cushion) arising from the superior and inferior haemorrhoidal veins in the submucosa of the rectum. The cause of haemorrhoids is not known. However, it is thought to be due to loosening due to degenerative effects of ageing leading to loosening of the connective tissue framework, supporting the haemorrhoid plexus veins. This along with the repeated passage of hard stool and straining produces a shearing force on the cushions, leading to their descent and prolapse.

Discuss the classification of haemorrhoids?
Internal or external (based on whether above or below the dentate line). They often occur together
Based on the degree of prolapse
First degree haemorrhoids: these bleed but do not prolapse
Second degree haemorrhoids: these prolapse but reduce spontaneously
Third degree haemorrhoids: these prolapse but can be reduced manually
Fourth degree haemorrhoids: these are permanently prolapsed and cannot be reduced

Discuss the symptoms of haemorrhoids?

Painless bleeding PR, itching, prolapse, discharge or soiling. Haemorrhoidal thrombosis can cause severe anal pain.
Classical position of the haemorrhoids is 3, 7 and 11’ o clock in left lateral position

Discuss management of haemorrhoids?
First and second degree haemorrhoids
Fibre supplementation helps bleeding and symptoms
Pruritus and discomfort are helped by topical anaesthetic or steroid creams
Definitive treatment with Rubber band ligation or injection sclerotherapy in indicated, if the above conservative measures fail. These procedures cause fibrosis and thus fix the mucosa of the prolapsed tissue back on to the underlying muscle.

Surgery is the treatment of choice for fourth degree haemorrhoids, symptomatic third degree haemorrhoids, strangulated and thrombosed haemorrhoids. Surgery may also be needed where outpatient treatment as above has failed. Choice of surgery- haemorrhoidectomy (open or closed) or stapled haemorrhoidopexy

Thrombosed piles usually settle with using ice packs, stool softeners, and analgesia. Topical calcium antagonists may help to relieve the pain. Surgery is sometimes needed.


  1. Acheson AG et al. Management of haemorrhoids BMJ 2008; 336:380-3
  2. http://www.bmj.com/content/336/7640/380.full?view=long&pmid=18276714

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