What are haemorrhoids?

Haemorrhoids ("piles") are the symptomatic enlargement and downward displacement of the anal cushions — normal vascular structures in the anal canal that help maintain fine continence. When their supporting connective tissue degenerates, the cushions become engorged, prolapse and bleed. Internal haemorrhoids arise above the dentate line (insensate — hence painless bleeding) and are graded I-IV; external haemorrhoids arise below it (sensate — hence painful when thrombosed). Symptoms: painless bright red bleeding (on paper, dripping, or coating the stool); prolapse or a lump; itching; mucus discharge; a feeling of incomplete evacuation. Contributing factors: constipation and straining; prolonged toilet sitting; low dietary fibre; pregnancy; ageing; chronic cough; heavy lifting.

Is rectal bleeding always haemorrhoids?

No — and assuming so is dangerous. Haemorrhoids are extremely common, so they are frequently present in people who also have colorectal cancer, inflammatory bowel disease or polyps. Finding haemorrhoids on examination does NOT exclude a more serious proximal cause. Rectal bleeding must be investigated (usually with colonoscopy or flexible sigmoidoscopy) if the patient is over the local age threshold (commonly 40-50), or has any of: a change in bowel habit; unintentional weight loss; iron deficiency anaemia; an abdominal or rectal mass; a family history of colorectal cancer or IBD; or bleeding that persists despite treatment. Blood MIXED INTO the stool, or dark blood, is particularly concerning for a proximal source, as opposed to the bright red blood on the surface or on paper that is typical of anorectal bleeding.

What treatments work for haemorrhoids?

Foundation for all grades: soluble fibre supplementation (ispaghula/psyllium — Cochrane evidence for reduced bleeding); adequate fluid; and behavioural change — do not strain, do not sit on the toilet for long periods (phone and reading are major modern contributors), and use a footstool to raise the knees above the hips. Grade I-II: the above ± short courses of topical preparations. Grade I-III: rubber band ligation — the most effective office procedure, applied above the dentate line, repeatable. Grade III-IV: excisional haemorrhoidectomy — the most effective and durable treatment, at the cost of 2-4 weeks of significant postoperative pain. Stapled haemorrhoidopexy and Doppler-guided artery ligation offer less pain but higher recurrence (HubBLe trial). Without the dietary and behavioural changes, recurrence after any procedure is high.

What is a thrombosed haemorrhoid and what should be done?

A thrombosed external haemorrhoid is a blood clot within an external haemorrhoid — presenting as a sudden, severely painful, tense, purple-blue lump at the anal margin, with pain peaking at 48-72 hours. Timing determines treatment. If the patient presents within 72 hours of onset (while pain is at its worst), excision of the thrombosed haemorrhoid under local anaesthetic provides immediate, dramatic relief and lower recurrence than simple incision and clot expression. If the patient presents after 72 hours, the pain is already improving as the clot organises, and conservative treatment is appropriate: oral analgesia, stool softeners, sitz baths and topical agents — the lesion resolves over 1-2 weeks, often leaving a painless skin tag that needs no treatment.

How can haemorrhoids be prevented?

Prevention and long-term control rest on the same measures: (1) Adequate soluble fibre — ispaghula/psyllium supplementation or dietary equivalent, to produce soft, formed stool that passes without straining. (2) Adequate fluid intake — fibre without fluid worsens constipation. (3) Do not strain, and do not sit on the toilet for prolonged periods. Prolonged sitting with the phone is one of the most significant and least-discussed modern contributors — the unsupported perineum and sustained venous engorgement directly promote cushion prolapse. (4) Respond promptly to the urge to defaecate rather than deferring. (5) A footstool raising the knees above the hips straightens the anorectal angle and reduces the straining required. (6) Regular physical activity and weight management. These measures are also what prevents recurrence after banding or surgery.

How does GMJ News cover haemorrhoids?

GMJ News covers the cardinal rule that rectal bleeding must not be attributed to haemorrhoids without excluding colorectal cancer, Goligher grading and grade-directed treatment, rubber band ligation technique (above the dentate line), the 72-hour window for thrombosed external haemorrhoid excision, anal fissure as the key differential (pain vs painless bleeding) and topical diltiazem vs GTN, haemorrhoidectomy techniques and the HubBLe trial, haemorrhoids in pregnancy, toilet behaviour and posture, and urgent referral criteria. Directly relevant to PHIG's colorectal, primary care and cancer early-diagnosis programmes.

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Haemorrhoids

GMJ News knowledge hub · last reviewed September 2026 · Georgian Medical Journal

Summary Statistics Glossary GMJ news FAQ Documents Organizations Research

Haemorrhoids — symptomatic enlargement and distal displacement of the normal anal cushions — are among the most common anorectal conditions worldwide, affecting an estimated 4-5% of adults symptomatically with far higher rates on examination, and are strongly associated with constipation, prolonged straining, low dietary fibre, pregnancy and prolonged sitting (WHO). The single most important clinical principle is that rectal bleeding must never be attributed to haemorrhoids without excluding colorectal malignancy in patients over 40, those with alarm features (weight loss, altered bowel habit, iron deficiency anaemia, family history) or those whose bleeding does not resolve with treatment — misattribution of cancer bleeding to haemorrhoids is a recurrent and well-documented cause of delayed colorectal cancer diagnosis and successful medicolegal claims.

Key messages

NEVER attribute rectal bleeding to haemorrhoids without excluding cancer

The single most important clinical rule. Rectal bleeding must not be attributed to haemorrhoids in: any patient over 40-50 (threshold varies by guideline and local colorectal cancer incidence); anyone with alarm features (unintentional weight loss, altered bowel habit, iron deficiency anaemia, abdominal or rectal mass, family history of colorectal cancer or IBD); or anyone whose bleeding persists despite treatment. Misattribution of colorectal cancer bleeding to visible haemorrhoids is a well-documented, recurrent cause of delayed cancer diagnosis and of successful medicolegal claims. The presence of haemorrhoids on examination does not exclude a synchronous proximal cancer.

Goligher grading determines treatment

Grade I: bleed but do not prolapse — conservative management (fibre, fluids, avoid straining) ± topical agents. Grade II: prolapse on straining, reduce spontaneously — conservative + office procedures (rubber band ligation first-line). Grade III: prolapse and require manual reduction — rubber band ligation or surgery. Grade IV: irreducibly prolapsed — surgery (haemorrhoidectomy). External haemorrhoids and thrombosed external haemorrhoids are graded separately and managed differently.

Rubber band ligation is the most effective office procedure

Rubber band ligation (RBL): bands applied to the haemorrhoidal pedicle ABOVE the dentate line (insensate — critical point: banding below the dentate line causes severe pain and is a technical error). Most effective non-surgical intervention for grade I-III internal haemorrhoids; superior to sclerotherapy and infrared coagulation in meta-analysis; can be repeated. Complications: pain (usually mild, from banding too low); delayed bleeding at 7-10 days when the band separates (occasionally significant); vasovagal episodes; and rarely, pelvic sepsis (a surgical emergency — presenting with severe pain, fever and urinary retention, requiring immediate assessment). Avoid RBL in anticoagulated patients and in immunosuppression.

Thrombosed external haemorrhoid — the 72-hour window

An acutely thrombosed external haemorrhoid presents as a sudden, exquisitely painful, tense purple perianal lump. If the patient presents WITHIN 72 hours of onset (pain at its peak), excision of the thrombosed haemorrhoid under local anaesthetic gives immediate and dramatic relief and reduces recurrence — this is excision, not simple incision and clot expression, which has higher recurrence. If the patient presents AFTER 72 hours (pain already improving as the clot organises), conservative management is appropriate: analgesia, stool softeners, sitz baths — the lesion resolves spontaneously over 1-2 weeks, often leaving a skin tag.

Anal fissure is the key differential — pain, not painless bleeding

Haemorrhoids characteristically cause PAINLESS bright red bleeding (blood on paper, dripping into the pan, coating rather than mixed into the stool). Severe pain during and after defaecation, often described as passing broken glass, with a small amount of bright blood, indicates ANAL FISSURE — a completely different condition. Fissure treatment: high-fibre diet, stool softeners, sitz baths, and topical vasodilators to reduce internal anal sphincter hypertonia — glyceryl trinitrate (GTN) 0.4% ointment or diltiazem 2% cream (better tolerated, less headache), for 6-8 weeks. Chronic fissure failing medical therapy: botulinum toxin injection or lateral internal sphincterotomy (highly effective but small risk of incontinence).

Fibre and defaecatory habit are the foundation — and the prevention

Conservative management underpins all treatment: soluble fibre supplementation (ispaghula/psyllium — Cochrane evidence for reduced bleeding and symptoms), adequate fluid, and — critically — behavioural change: do not strain; do not sit on the toilet for prolonged periods (reading, phone use — a major and under-addressed contributor); respond promptly to the call to stool. Toilet posture with the knees elevated above the hips (a footstool) straightens the anorectal angle and reduces straining. These measures both treat existing haemorrhoids and prevent recurrence after any procedure — without them, recurrence rates after banding or surgery are high.

Key statistics

4-5%

of adults report symptomatic haemorrhoids; far higher prevalence on examination

ASCRS/ACPGBI

Never assume

rectal bleeding is haemorrhoidal without excluding colorectal cancer in at-risk patients

NICE/ASCRS

Above dentate

rubber band ligation must be applied above the dentate line — below causes severe pain

ASCRS

72 hours

window for excision of a thrombosed external haemorrhoid — after this, manage conservatively

ASCRS

Painful = fissure

severe pain on defaecation indicates anal fissure, not haemorrhoids — different treatment

ASCRS/ACPGBI

Diltiazem 2%

topical — as effective as GTN for anal fissure with substantially fewer headaches

Cochrane

Haemorrhoid treatment by Goligher grade (ASCRS guidelines)

Source: ASCRS/ACPGBI. Conservative measures underpin all grades; rubber band ligation is the most effective office procedure.

Glossary of key terms

Anal cushions and the dentate line
AnatomyThe anal cushions are normal vascular structures — submucosal arteriovenous plexuses supported by connective tissue (Treitz's muscle) — located in the left lateral, right anterior and right posterior positions. They contribute approximately 15-20% of resting anal continence pressure and are essential for fine continence of gas and liquid. Haemorrhoids are not varicose veins: they are these normal cushions that have become engorged and distally displaced through degeneration of their supporting connective tissue. This is why complete excision of all cushions impairs continence — and why treatments aim to reduce and refix rather than eradicate. The dentate (pectinate) line marks the transition from insensate visceral (columnar, above) to exquisitely sensitive somatic (squamous, below) innervation — the single most important landmark in anorectal intervention.

Goligher classification
Colorectal surgeryThe standard grading of internal haemorrhoids: Grade I — bleed but do not prolapse below the dentate line. Grade II — prolapse on straining or defaecation but reduce spontaneously. Grade III — prolapse and require manual reduction. Grade IV — permanently prolapsed and cannot be reduced (includes acutely thrombosed or strangulated internal haemorrhoids). External haemorrhoids (arising below the dentate line, covered by squamous anoderm) are not included in this grading and are managed separately; skin tags are the residue of previous external thrombosis and require no treatment unless causing hygiene difficulty.

Haemorrhoidectomy techniques
Colorectal surgeryConventional excisional haemorrhoidectomy (Milligan-Morgan open, or Ferguson closed): the most effective and durable treatment, with the lowest recurrence — but the most postoperative pain (typically 2-4 weeks). Stapled haemorrhoidopexy (PPH): excises a circumferential ring of rectal mucosa above the dentate line and repositions the cushions; less immediate pain but higher recurrence and prolapse rates, and rare but severe complications (rectovaginal fistula, pelvic sepsis, rectal stenosis) — NICE and several national bodies have restricted its use. Haemorrhoidal artery ligation with recto-anal repair (HALO/THD, Doppler-guided): less pain than excision, but the HubBLe trial (Lancet 2016) found higher recurrence than rubber band ligation at 1 year and no cost-effectiveness advantage. Excisional haemorrhoidectomy remains the gold standard for grade III-IV disease.

Anal fissure — pathophysiology and treatment
ColorectalAn anal fissure is a longitudinal tear in the anoderm, most commonly in the posterior midline (approximately 90%; anterior midline in 10%, more common in women postpartum). Pathophysiology: internal anal sphincter hypertonia → reduced anodermal blood flow → the posterior midline is a relative watershed area → ischaemia prevents healing → pain causes further sphincter spasm (a vicious cycle). Treatment therefore targets sphincter relaxation: topical GTN 0.4% or diltiazem 2% for 6-8 weeks (diltiazem preferred — equally effective, far fewer headaches); plus stool softening and sitz baths. Refractory chronic fissure: botulinum toxin injection into the internal sphincter (temporary chemical sphincterotomy) or lateral internal sphincterotomy (highest healing rate, approximately 95%, but carries a small risk of flatus or faecal incontinence — counsel carefully, particularly in women with obstetric sphincter injury). IMPORTANT: fissures that are lateral, multiple, irregular or painless are NOT typical — investigate for Crohn's disease, tuberculosis, HIV, syphilis, or anal carcinoma.

Haemorrhoids in pregnancy
ObstetricsVery common — driven by increased circulating volume and progesterone-mediated venous laxity, gravid uterine pressure on pelvic veins, constipation, and the acute strain of the second stage of labour. Management is predominantly conservative: dietary fibre and fluids; bulk-forming laxatives (ispaghula) and macrogol are safe in pregnancy; topical preparations containing local anaesthetic and low-potency corticosteroid for short-term symptomatic relief; sitz baths; avoid prolonged standing. Most postpartum haemorrhoids and acute thromboses regress substantially within weeks of delivery. Surgery is generally deferred until at least 3-6 months postpartum unless there is strangulation or intractable bleeding — allowing spontaneous improvement and avoiding unnecessary intervention.

When to refer urgently
NICE/Primary careUrgent lower GI investigation (suspected cancer pathway) is required for: rectal bleeding with a change in bowel habit; rectal bleeding in patients above the local age threshold (commonly 40-50) without an obvious anorectal cause; iron deficiency anaemia; unintentional weight loss; abdominal or rectal mass; persistent bleeding despite treatment of an apparent anorectal cause. Emergency surgical assessment is required for: strangulated or gangrenous prolapsed haemorrhoids (severe pain, necrotic mucosa); severe post-banding pain with fever or urinary retention (possible pelvic sepsis — rare but life-threatening); and profuse bleeding causing haemodynamic compromise.

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