Describe Haemorrhoids in detail.

The Concept

Haemorrhoids ('piles') are the symptomatic enlargement and downward displacement of the anal cushions — normal masses of vascular submucosal tissue in the anal canal. Everyone has anal cushions (they help seal the anus and maintain continence); they become 'haemorrhoids' only when they enlarge, engorge and prolapse and cause symptoms. Understanding them as displaced normal cushions rather than varicose veins makes the classification and treatment logical.

Anatomy & Types

The anal cushions lie in three constant positions — 3, 7 and 11 o'clock (left lateral, right anterior and right posterior with the patient in the lithotomy position). Haemorrhoids are classified by their relation to the dentate line:

• Internal haemorrhoids — above the dentate line, covered by insensate columnar mucosa, so they are typically painless.
• External haemorrhoids — below the dentate line, covered by sensate squamous epithelium, so they are painful when thrombosed.

Grading of Internal Haemorrhoids

Aetiology & Clinical Features

Contributing factors are constipation and straining, a low-fibre diet, pregnancy, and any cause of raised intra-abdominal pressure. The typical symptom is bright red, painless bleeding (coating the stool or dripping after defecation), with prolapse, mucus discharge, pruritus and discomfort; pain occurs only with thrombosis or strangulation.

Examination & Management

Examination involves inspection, digital rectal examination (internal piles are usually not palpable), and proctoscopy to visualise them. Crucially, in any patient with rectal bleeding one must exclude colorectal cancer with sigmoidoscopy/colonoscopy rather than assume the bleeding is from piles. Management is graded:

• Conservative (grades I–II) — high-fibre diet, fluids, avoiding straining, and stool softeners.
• Non-surgical (II–III) — rubber-band ligation, sclerotherapy, or infrared coagulation.
• Surgical (III–IV or failed treatment) — haemorrhoidectomy (open Milligan–Morgan or closed Ferguson), or stapled haemorrhoidopexy.

WHY They Are Not Varicose Veins

A common misconception is that haemorrhoids are 'varicose veins of the anus'. In fact the modern understanding is that they are displaced anal cushions — the normal vascular submucosal tissue that helps seal the anal canal. With chronic straining, the supporting connective tissue that anchors these cushions fragments and stretches, allowing them to slide downward and engorge. This is why treatment aims to fix the cushions back in place or reduce their bulk (band ligation, haemorrhoidopexy) rather than simply 'removing a vein', and why straining prevention is central.

Thrombosed & Strangulated Haemorrhoids

The painful complications deserve attention. A thrombosed haemorrhoid occurs when a clot forms in a prolapsed pile, causing sudden severe pain and a tense, tender swelling. A strangulated haemorrhoid arises when prolapsed piles are gripped by the sphincter, cutting off their venous return and causing intense pain, oedema and possible gangrene. These acute presentations are managed initially with analgesia, ice, stool softeners and rest (most settle), with surgery reserved for severe or gangrenous cases — a contrast to the painless bleeding of uncomplicated internal piles.

A Note on Excluding Sinister Causes of Bleeding

The most important safety principle in managing 'piles' bears repeating: rectal bleeding must never be assumed to be haemorrhoidal without excluding colorectal cancer, particularly in patients over 40, those with a change in bowel habit, weight loss, anaemia, or a family history. Haemorrhoids are extremely common and may coexist with a cancer, so attributing bleeding to visible piles can dangerously delay a cancer diagnosis. A full lower-GI evaluation (colonoscopy) is therefore the rule for significant or atypical bleeding, whatever the anal findings.

A Note on Haemorrhoids in Pregnancy & Portal Hypertension

Two special contexts are worth noting. In pregnancy, haemorrhoids are common because of the combination of raised intra-abdominal pressure, constipation and the vascular effects of progesterone; they usually improve after delivery, so treatment is conservative (fibre, fluids, topical measures) during pregnancy. Separately, it is a classic teaching point that although engorged, haemorrhoids are not simply a manifestation of portal hypertension — the true portosystemic connection in that condition is anorectal varices, a distinct entity, and it is important not to confuse the two.

• Anal cushions at 3, 7, 11 o'clock; internal (above dentate line, painless) vs external (below, painful if thrombosed).
• Grading: I bleed only, II prolapse + spontaneous reduction, III need manual reduction, IV irreducible.
• Always exclude colorectal cancer (colonoscopy) in rectal bleeding; band ligation (II–III), haemorrhoidectomy (III–IV).

They lie at 3, 7 and 11 o'clock in the lithotomy position.

• Haemorrhoids = symptomatic enlargement/prolapse of the normal anal cushions (3, 7, 11 o'clock).
• Internal (above dentate line, painless bleeding) vs external (below, painful if thrombosed); internal graded I–IV.
• Bright red painless bleeding, prolapse, mucus, pruritus; pain only with thrombosis/strangulation.
• Always exclude colorectal cancer with colonoscopy in a patient with rectal bleeding.
• Conservative (fibre/fluids, I–II), band ligation/sclerotherapy (II–III), haemorrhoidectomy (III–IV).