Haemorrhoids or Piles are abnormal swellings of the vascular mucosal 
anal cushions around the anus Common in general population Have been treated by surgeons for centuries Affect between 4.4 and 36.4 % of the general population Cost range US $ 1-1.5 Billion dollars annually ( US )
Exact incidence is difficult to quantify as people always do not seek help Peaks between 45-65 yrs and seen more in white people and people of higher socioeconomic group Evidence indicates that bleeding is arterial and not venous ( bright red colour and pH of blood ) Particularly common in women during pregnancy and post-partum Treatment based on degree of prolapse and severity of symptoms

Thomson was the first to introduce the concept of ‘ anal cushions ‘ usually 3 in number – in left lateral , rt anterior and rt posterior positions
3 , 7 , 11 o clock 

These help maintain anal continence

When they become enlarged and symptomatic – they are called 
haemorrhoids

Classified by their anatomic origin within the anal canal ( see image ) by their position relative to the Dentate ( Pectinate in image ) line – patients can have both simultaneously External-Below the dentate line Develop from ectoderm squamous epithelium innervated by cutaneous nerves that supply peri-anal area -
○ pudendal nerve
○ sacral plexus
ie they can be painful and itchy

Internal-Above the dentate line Columnar epithelium No somatic N supply so not sensitive to touch , temp or pain → unless strangulated Drain through the superior rectal vein into inferior vena cava 

Presentation can be non-specific from
○ bright red painless rectal bleeding ( not mixed with stool ) on defecation or straining 
patients describe blood may drip , squirt into the toilet bowl or appear as streaks on the toilet paper

○ pain , pruritis , prolapse , soiling
○ thrombosed external piles → painful rectal mass Darker blood or blood mixed with stool → suspect more
proximal cause of bleeding Examine in left lateral position , the prone jack-knife position or the lithotomy position 

○ abdominal examination
○ inspect visually 
○ digital rectal examination → must 
○ anoscopy or proctosigmoidoscopy if facilities expertise exist Examination-mucous discharge → can cause irritation prolapsed internal haemorrhoids → not usually palpable unless thrombosed acute thrombosed external piles → purplish , oedeomatous , tense , tender s/c perianal mass fissures ,fistula anal tags , skin tags from old thrombosed external piles masses , tenderness , blood rectal tone prostate in men signs of infection , abscess

Several contributing factors have
 been proposed which form the basis of treatment and include

○ lack of dietary fiber
○ prolonged straining
○ spending excess time in commode
○ constipation
○ diarrhoea
○ pregnancy
○ sedentary lifestyle
○ family history

Non-prolapased
 internal haemorrhoids will
 not be evident on external examination and are 
difficult to feel on digital 
rectal examination General measures-Address constipation Fluid intake , balanced diet
↑ fiber intake > 25 g/ Day Anal hygiene Warm baths Bulk forming laxatives Non-opioid analgesia Topical haemorrhoid preparations External piles- thrombosed painful ( within 72 hrs )

Presentation beyond 72 hrs can be managed conservatively with ice packs, stool softeners , topical calcium channel antagonists & tends to improve in 10-14 days
 Internal piles → swollen , prolapsed ,incarcerated and thrombosed Infection → perianal sepsis Perianal haematoma ( < 24 hrs for extraction ) Another serious pathology suspected 3rd and 4 th degree haemorrhoids Combined internal and extenal + severe symptoms No response to conservative management or recurrent symptoms Thrombosed haemorrhoids ( if not referred acutely ) when bleeding is problematic Chronic irritation or leakage Large skin tags

No evidence any topical preparation is more effective than other Topical steroids – use short term ( 7 days ) and exclude infections
prolonged use can cause skin atrophy , contact dermatitis & skin sensatization No topical haemorrhoidal preparation is licensed for use during pregnancy
Although soothing products without steroids or LA’s can be used as risk of harm to the mother or fetus is unlikely
 Advice to use morning & night + after bowel movements Some transient burning may happen

Non-surgical treatment 
( often called office based ) can include
 rubber band ligation
( Most common ) bipolar diathermy injection sclerotherapy dilation cryotherapy infra-red coagulation

Surgical management includes options as excision haemorrhidectomy stapled haemorrhoidectomy doppler guided trans-anal devascularization anopexy / HAL

References

1. Hemorrhoids – EMedicine Scott C Thornton MD et al Updated January 2018
2. BMJ Best Practice- Haemorrhoids
3. NICE Treatment summary – Haemorrhoids NICE Radiofrequency treatment of haemorrhoids August 2017 https://www.nice.org.uk/guidance/IPG589
4. Hemorrhoids Am Fam Physician . 2011 Jul 15 ; 84 (2) : 204-210
5. Management of haemorrhoids BMJ 2008 ; 336 : 380
6. NICE CKS Haemorrhoids July 2016 https://cks.nice.org.uk/haemorrhoids
7. Hardy A, Chan C, L, H, Cohen C, R, G: The Surgical Management of Haemorrhoids – A Review. Dig Surg 2005;22:26-33. doi: 10.1159/000085343 https://www.karger.com/Article/Fulltext/85343#
8. Hemorrhoids Jennifer K. Lee MD et al Seminars in Colon & Rectal Surgery
9. Management of haemorrhoids accessed via http://www.enhertsccg.nhs.uk/sites/default/files/pathways/
Management%20of%20Haemorrhoids.pdf
10. BNF Haemorrhoids- https://bnf.nice.org.uk/treatment-summary/haemorrhoids.html
11. Fontem RF, Eyvazzadeh D. Internal Hemorrhoid. [Updated 2019 Nov 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537182/
12. Recent advances in the management of hemorrhoids
    Mahmoud Sakr, Khaled Saed
    Mahmoud Sakr, Khaled Saed, Department of Surgery, Faculty of Medicine, University of Alexandria, Alexandria 21500, Egypt

    World J Surg Proced. Nov 28, 2014; 4(3): 55-65
    Published online Nov 28, 2014. doi: 10.5412/wjsp.v4.i3.55