Haemorrhoids, or piles, are a common complaint which patients tend to use as a 'catch-all' diagnosis to encompass a variety of anal conditions. To the colorectal surgeon, haemorrhoids refer to the symptoms that arise from the anal cushions. These cushions are three submucosal spaces filled with arteriovenous communications, which lie in the upper half of the anal canal and help to keep it 'airtight' at rest. Haemorrhoids are said to have occurred when the cushions bleed or prolapse, or both. Haemorrhoids have been arbitrarily classified as:
• First degree: bleeding alone.
• Second degree: prolapse on defaecation with spontaneous reduction.
• Third degree: prolapse on defaecation requiring manual reduction.
• Fourth degree: prolapse on defaecation, unable to replace. The bleeding of haemorrhoids is classically bright red in colour and seen on the toilet paper or in the toilet pan. A rectal neoplasm can produce similar bleeding and steps must be taken to exclude such a lesion. Flexible sigmoidoscopy is the investigation of choice in bright red rectal bleeding. Advice about dietary changes (to include more fibre and fluid) may be sufficient to manage some haemorrhoidal symptoms. Other interventions may be in the outpatient setting or surgical.
Outpatient treatment for haemorrhoids is usually by the application of rubber bands or by injection of 5% phenol in almond or arachis oil as a sclerosant. A recent meta-analysis suggested that rubber-band ligation was better than sclerotherapy.
Surgical haemorrhoidectomy is usually described as the Milligan-Morgan technique, with excision of the three cushions to leave a 'clover leaf' type wound in the anal canal. This is a painful operation and careful attention should be paid to the perioperative regime. Pre- and postoperative aperients, intraoperative local anaesthetic with postoperative balanced analgesia and antibiotics is thought to be the optimal regime.
Skin bridges need to be preserved between the pile excision wounds to prevent anal stenosis.
In 1998, Longo introduced a new surgical approach to haemorrhoids, stapled haemorrhoidectomy or procedure for prolapsed haemorrhoids (PPH). In this technique, a circumferential strip of mucosa is excised from above the dentate line by use of a stapling device. Pain is less compared to conventional surgical haemorrhoidectomy, with earlier return to the activities of daily living. Initial enthusiasm for this procedure has been tempered by reports of rare, but very serious, complications such as sepsis and anovaginal fistulation and the technique is clearly operator dependant.
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