Haemorrhoids

Symptoms

In general, patients with varying rectal complaints seek medical attention complaining of “haemorrhoids”. True haemorrhoidal symptoms, however, are relatively specific.

There are two cardinal symptoms of internal haemorrhoids:
Rectal bleeding	Patients either present with bright red blood per rectum or a prolapsing anal mass. Bleeding associated with haemorrhoids generally occur with, or following, bowel movements, is almost universally bright red, and very commonly drips into the toilet water. Blood may also be seen while wiping after defecation. Occasionally blood may stain the underclothes if haemorrhoidal prolapse is present. Bleeding associated with haemorrhoids is rarely mixed with the stool, dark, or melanotic in nature. Rarely individuals with large chronic haemorrhoids may present with anaemia secondary to chronic blood loss.
Prolapse with mucosal irritation	Haemorrhoidal prolapse usually occurs in association with a bowel movement, particularly when straining is present. Haemorrhoids may also prolapse during walking or heavy lifting as a result of increased intra-abdominal pressure. The prolapse is associated with a full, uncomfortable feeling, which resolves when the prolapse reduces. If incarcerated prolapse occurs then strangulation may develop. In this circumstance, patients present with extreme pain, bleeding and occasionally signs of systemic illness. These individuals may require urgent haemorrhoidectomy.

Evaluation of rectal bleeding

Anorectal bleeding is commonly associated with haemorrhoids but may certainly be a harbinger of many anorectal abnormalities including colorectal cancer. Any individual with rectal bleeding should undergo an appropriate, thoughtful workup to rule out rectal cancer. In a young individual with bleeding associated with haemorrhoidal disease and no other systemic symptoms, and no family history, perhaps rectoscopy and flexible sigmoidoscopy are all that is warranted. However, in an older individual, with either a family history of colorectal cancer, or change in bowel habits, a complete colonoscopy should be performed to rule out proximal neoplasia.