Symptomatic enlargement of anal vascular cushions; internal (above dentate line) or external.
History taking
- • Painless bright red bleeding per rectum, prolapse, pruritus, mucus discharge
- • Constipation, straining, pregnancy, low-fibre diet
Examination
- • Inspection: skin tags, prolapse on straining
- • PR exam, proctoscopy to grade internal piles (I–IV)
- • Exclude other causes of PR bleeding
Red flags
- • Age >40 with PR bleed — rule out colorectal malignancy
- • Weight loss, change in bowel habit, anaemia
- • Severe pain (thrombosed external pile or fissure)
Differential diagnosis
- • Anal fissure, anal cancer, rectal polyp, IBD, rectal prolapse
Recommended investigations
- • Proctoscopy mandatory
- • Colonoscopy in age >40, anaemia, change in bowel habit, family history of cancer
Diagnosis
- • Clinical + proctoscopy with grading
Initial treatment / management
- • Grade I–II: lifestyle (high-fibre, fluids), bulk-forming agents, topical agents
- • Grade II–III: rubber band ligation, sclerotherapy
- • Grade III–IV/Thrombosed: surgery (haemorrhoidectomy, stapled)
- • Thrombosed external pile <72 h: excision under LA
Prescription examples
- • Tab Ispaghula husk 1 sachet PO HS in water
- • Topical Lignocaine + Hydrocortisone cream BD x 7 d
- • Tab Diosmin 1000 mg PO BD x 4 d then 500 mg BD x 3 d (acute attack)
- • Sitz baths warm water TDS
Follow-up advice
- • Review at 4 weeks; further intervention if symptoms persist
Patient counselling
- • High-fibre diet, fluids 2.5 L/day, avoid straining and prolonged toilet sitting
- • Recurrence common — lifestyle is key
Referral criteria
- • Grade III/IV, recurrent bleeding, suspicion of malignancy
Clinical pearls
- • Never attribute PR bleed to piles in older patients without colonoscopy
- • Thrombosed pile pain peaks at 48–72 h then resolves spontaneously over 1–2 weeks
References
- • ASCRS Clinical Practice Guidelines for Hemorrhoids 2018
- • NICE CG49: Lower GI bleeding
Educational outpatient guide — verify against local guidelines before clinical use.
