Introduction 

The condition of “Haemorrhoids” or “Haemorrhoidal Disease” is diagnosed when abnormalities are found within the “anal cushions”. These are a normal part of the anal canal of every individual patient and only become a disease when not functioning correctly.

The lining of the anal canal (mucosa) is analogous to that of the mouth. It is held in place by tiny ligaments that attach it to the underlying muscles of the anal sphincter. Between the mucosa and the muscle are found complex channels of veins which, depending upon the amount of blood within them, bulge into the anal canal. These structures (mucosa, ligaments and veins) make up the anal cushions. When functioning normally these cushions can be thought of as part of the mechanism by which continence is maintained.

What happens when things go wrong?

Engorgement of the system of veins within the anal cushions can lead to weakness within the vessel wall. Trauma to the mucosa on opening the bowels can lead to damage of the vein wall. This engorgement may, with time lead to rupture of the ligaments holding the mucosa in place. As a result disruption to the normal delicate functioning of the anal cushions leads to alteration in continence. Following this the cardinal features of haemorrhoidal disease are seen.

1. Discomfort (Due to engorged veins and mucosal trauma) with opening the bowels
2. Bleeding (Due to injury to the mucosa and walls of the veins)
3. Prolapse (Or swelling, felt outside the anal canal as the mucosa is squeezed out)
4. Mucous Discharge (Seepage from the anal canal through an now incompetent sphincter)
5. Itching (From mucous and stool that soils the skin around the anal canal)

Why do haemorrhoids occur?

The whole truth as to why patients get Haemorrhoids is not known but what is for certain is that the main contribution comes from disordered evacuatory habit of every kind. Any condition that causes a rise in pressure in the anal canal, usually generated to assist with difficult evacuation, will cause the changes described above. These are most commonly:-

1. Constipation (and Diarrhoea)
2. Straining and sitting for prolonged periods on the lavatory
3. Low fibre in the diet
4. Pregnancy and Childbirth

It is for these reasons that to a large extent haemorrhoidal disease is recognised as a cultural rather than pathological phenomenon.

Severity and Grading of Symptoms

• Grade I Disease: Haemorrhoids (mucosa, ligaments and veins) remain in the anal canal may be uncomfortable and bleed
• Grade II Disease: Haemorrhoids prolapse outside the anal canal and return spontaneously
• Grade III Disease Haemorrhoids prolapse outside the anal canal on opening the bowels and must be pushed back with a finger
• Grade IV Disease Haemorrhoids remains outside at all times

Treatment

Grade I and II  – Conservative measures

• High Fibre Diet
• Topical treatment (ointments- local anaesthetic/ steroid) used intermittently for a few days only
• Injections
• Banding

Grade III

• As for Grade I and II
• Surgery (Haemorrhoidectomy/ haemorrhoid artery ligation-HALO/ )

Grade IV

• Surgery (Haemorrhoidectomy)

Banding and injection of haemorrhoids attempts to achieve two main effects. The first is interuption of bloodflow within the venous channels of the submucosa, the second is to cause inflammation in the submucosa which creates scarring and stops mucosa slipping and prolapsing. Banding is thought to be slightly more efficacious. In both techniques the band or injection is placed above the haemorrhoid where, theoretically at least, there are no pain fibres (nerves). The procedure is carried out in outpatients (often combined with a flexible sigmoidoscopy) and takes just a few minutes.

A painkilling suppository may be inserted to maintain comfort after completion. It is adviseable to take a simple oral painkiller (eg. Paracetamol) regularly for 48 hours afterwards. Complications such as worsening pain or sustained bleeding, fever and chills are very unusual after either type of treatment but should be reported to your surgeon. The sucess rate in controlling symptoms in appropriately chosen patients is of the order of 80%. The procedure may be repeated multiple times without complication.