GPAtlas🧭 When to suspect
Haemorrhoids ("piles") are symptomatic, abnormally enlarged vascular cushions in the anal canal, and are extremely common.
• They are classified as internal (arising above the dentate line) or external (below it).
• They are precipitated by constipation and straining, pregnancy and childbirth, increasing age, a low-fibre diet, and prolonged sitting or heavy lifting.
The hallmark is painless, bright-red rectal bleeding – seen on the paper or coating (but not mixed through) the stool.
• Other features are anal itching (pruritus ani), mucus discharge or soiling, and a lump or prolapse at the anal margin.
• Pain is usually absent unless a haemorrhoid becomes thrombosed or strangulated.
• A confident diagnosis requires examination – digital rectal examination (DRE) and proctoscopy – after excluding colorectal and anal cancer.
• In practice, cancer is excluded with examination and a faecal immunochemical test (FIT).
Internal haemorrhoids are graded by the degree of prolapse using the Goligher classification, which broadly guides management.
| Goligher grade | Features | Usual management |
|---|---|---|
| Grade I | • Bulge into the lumen • Bleed but do not prolapse |
Conservative (stool optimisation ± topical) |
| Grade II | Prolapse on straining, reduce spontaneously | • Conservative • Banding if persistent |
| Grade III | Prolapse and require manual reduction | Conservative ± outpatient banding or surgery |
| Grade IV | Permanently prolapsed, irreducible (± thrombosis) | Surgical referral |
|
🧠 Clinical pearl – the dentate line explains the symptoms • Internal haemorrhoids sit above the dentate line under insensate rectal mucosa – so they bleed but rarely hurt. • External haemorrhoids sit below the dentate line under sensitive anoderm, and become exquisitely painful when thrombosed. • Painless bleeding points to internal piles. • Sudden severe anal pain points to a thrombosed external pile or a fissure – not to uncomplicated internal haemorrhoids. |
Source: NICE
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