Haemorrhoids are enlarged vascular cushions (the vascular cushions are sections of fibrovascular tissue within the anal canal which help control continence by enlarging when needed to provide a firm seal).
Internal haemorrhoids – stem from the superior rectal veins (not true varicosities, but the module didn’t say what they are). Seen on proctoscopy. Covered with mucosa that is not sensitive to touch, so usually present with painless bleeding. If prolapsed, are soft and tender.
External haemorrhoids – varicosities of the tributaries of the inferior rectal vein. Covered by skin that is sensitive to touch and pain. Appear as perianal lumps.
Thrombosed external haemorrhoids – acutely tender, dark purple/black in colour, usually not reducible, may be too painful for rectal examination to be tolerated.
Internal haemorrhoids are graded according to degree of prolapse:
- No prolapse
- Prolapse but reduce spontaneously
- Prolapse but can be manually reduced
- Prolapsed, cannot be reduced
External haemorrhoids count as Grade 4.
Resolved external haemorrhoids can leave skin tags, which can cause irritation/difficulty with hygiene.
There’s a new treatment – oral bioflavonoids. These stabilise venous tone, inhibit prostaglandin release, and have been shown to reduce bleeding both from haemorrhoids and after haemorrhoid surgery. Whether they do anything else for symptoms was not stated in this module, but they aren’t available for prescription anyway. The one studied in primary care is called Daflon and is given at 1g tds for four days then 1g bd for six days.
High fibre diets reduce recurrence of symptoms after banding.
(BMJ learning modules: Haemorrhoids – diagnosis and management. Haemorrhoids in primary care)