AKT · Gastroenterology/Anorectal

Haemorrhoids

Engorged anal vascular cushions (raised pressure: straining/constipation/pregnancy)

Overview

Symptomatic enlargement of the anal vascular cushions, driven by raised pressure (constipation/straining, pregnancy, low fibre). Internal haemorrhoids cause PAINLESS bright-red rectal bleeding (on the paper/coating the stool) ± prolapse; external/thrombosed ones are painful. Graded I–IV. Managed with fibre/fluids and topical agents; banding or surgery for higher grades. The rule: never attribute rectal bleeding to haemorrhoids without excluding cancer in at-risk patients.

Recognise

PAINLESS bright-red rectal bleeding (on wiping/coating stool, not mixed in), pruritus, mucus, a sense of incomplete evacuation; prolapsing lump
Grades: I (no prolapse) → II (prolapse, reduces spontaneously) → III (needs manual reduction) → IV (irreducible)
Thrombosed external haemorrhoid: acutely painful, tense, tender perianal lump

Red flags

Rectal bleeding with change in bowel habit, weight loss, anaemia, or age ≥50/≥60 → investigate for COLORECTAL CANCER, don't assume haemorrhoids
Anaemia from bleeding

Differentials & how to tell them apart

Colorectal cancerchange in habit, weight loss, anaemia, blood mixed IN the stool — exclude with colonoscopy

Anal fissurePAIN on defecation with a small amount of bright blood

IBDdiarrhoea with blood/mucus, systemic features

Anal cancermass/ulcer, HPV risk

Investigations

Clinical: inspection, PR exam, PROCTOSCOPY (internal haemorrhoids). Investigate red flags (colonoscopy) — bleeding is not assumed to be haemorrhoidal in at-risk patients.

Management

Fibre/fluids + topical agents; banding/surgery for higher-grade disease

1Confirm with proctoscopy. Conservative: high fibre, fluids, avoid straining; topical agents for symptoms.Gate: Do NOT attribute rectal bleeding to haemorrhoids in at-risk patients (change in habit, weight loss, anaemia, older age) without excluding COLORECTAL CANCER (colonoscopy)
2Persistent grade I–II → rubber-band ligation/sclerotherapy; grade III–IV/refractory → haemorrhoidectomy; thrombosed external → analgesia ± excision if early/severe.

Fibre + fluids + avoid straining — first-line — soften stool, reduce pressure

Topical agents (short-term) — soothing/local anaesthetic/steroid creams for symptom relief

Rubber-band ligation / sclerotherapy / haemorrhoidectomy — for higher grades/refractory

Key points

Painless bright-red bleeding on wiping + prolapse = haemorrhoids → fibre/fluids/topical, band higher grades. The safety rule: exclude cancer before blaming haemorrhoids in older patients or those with red flags.

Monitor & prognosis

Symptoms; recurrence.

Good; recurrence with ongoing constipation.

Source: NICE CKS Haemorrhoids