Haemorrhoids

Enlarged, symptomatic vascular cushions of the anal canal: internal (above dentate line, painless unless complicated) or external (below, richly innervated, painful if thrombosed).

Graded I-IV by degree of prolapse (I no prolapse; II prolapse, spontaneous reduction; III requires manual reduction; IV permanently prolapsed).

Painless bright red rectal bleeding (classic internal hemorrhoid presentation), pruritus ani, mucus discharge, prolapse sensation. Significant pain suggests complication (thrombosis) or alternative diagnosis.

Thrombosed external: sudden severe pain, palpable tender bluish lump.

Risk factors: chronic straining/constipation, pregnancy, obesity, prolonged sitting, low-fiber diet.

Inspection, DRE, proctoscopy/anoscopy.

Critical: rectal bleeding requires exclusion of more serious pathology, especially age >50, bowel habit change, weight loss, family history: colonoscopy/sigmoidoscopy indicated per red flags/screening criteria even if hemorrhoids visualized.

FBC if significant/chronic bleeding.

Differentials: anal fissure (severe defecation pain, visible tear), colorectal malignancy (must exclude), perianal abscess/fistula, rectal prolapse, condylomata, IBD.

• Conservative (first-line): high-fiber diet, fluids, avoid straining, stool softener, warm sitz baths
• Topical: hydrocortisone/local anesthetic combination, short courses only (skin atrophy risk)
• Venotonic agents (diosmin/hesperidin): adjunctive
• Office procedures (Grade I-III refractory): rubber band ligation (most common), sclerotherapy, infrared coagulation
• Thrombosed external: excision under local anesthesia if <72h with significant pain; conservative if later presentation/improving
• Surgical hemorrhoidectomy: Grade III-IV refractory to office management, large external component; stapled hemorrhoidopexy alternative (less pain, higher recurrence)

Referral: colorectal surgery/gastroenterology for red flag bleeding requiring endoscopy, Grade III-IV disease, failed conservative/office management.