haemorrhoids (piles)

haemorrhoids (piles) are swellings arising from the anus that may bleed or cause the area to be itchy or painful. They are a common condition and many of us will experience them to a certain degree at some time during our lives. They are especially common in women during pregnancy. The majority of haemorrhoids resolve spontaneously, but persistent symptoms, especially of bleeding in people over 50 years old, may need investigation as, rarely, they can mimic other more serious bowel disease such as cancer. Haemorrhoids are the most common cause of bleeding from the anus; the bleeding usually occurs after passing a bowel motion and will appear on the toilet paper.

Haemorrhoids have been recognized and treated for at least 4000 years. The term itself, as described by Hippocrates, comes from the Greek, haema — blood — and rhoos — flowing. Despite their common occurrence and extended history the exact cause of haemorrhoids is still unclear. In medieval times it was thought that haemorrhoids were enlarged veins that expelled superfluous melancholy humours. The concept of haemorrhoids as enlarged veins persisted until recently, when detailed anatomical studies demonstrated their soft tissue nature and the close association they have with the normal anus. Many long-held beliefs regarding the exact cause of haemorrhoids have been difficult to prove scientifically. Generally accepted associations are that haemorrhoids occur more frequently in those who are constipated, strain excessively when passing a bowel motion, or spend a long time sitting (especially on the toilet seat). In some cases a genetic component for the formation of haemorrhoids may well be responsible.

Haemorrhoids arise from the three cushions of tissue just inside the anus that normally function to give a watertight seal. These cushions may be damaged, bleed, or be pushed down by the passing bowel motion, thus forming a haemorrhoid. If trapped outside the anus the haemorrhoid's blood supply may be disrupted, causing the severe pain of a ‘thrombosed pile’.

The cornerstone of treatment and prevention of haemorrhoids is a high-fibre diet, producing a soft bowel motion that is easy to pass without straining. Combined with this it is important to avoid sitting for prolonged periods or excessive wiping of the anus after passing a bowel motion. Use of a moist cloth, wet wipe, or lying in a bath filled with lukewarm water are also helpful when the haemorrhoids cause symptoms. Historically, anaesthetic creams have been used to reduce the pain felt locally; however these may be irritating to the skin and should be considered secondary to other measures. If basic treatment fails, outpatient ‘banding’, injection, or freezing treatments can shrink the haemorrhoid, thus speeding resolution. Surgical treatment, where the haemorrhoids are removed at operation (haemorrhoidectomy) is used less frequently now, as outpatient treatment is very effective.

G. A. Smith, and P. J. O'Dwyer