GPAtlas🧭 When to suspect
Haemorrhoids ("piles") are symptomatic, abnormally enlarged vascular cushions in the anal canal. They are classified as internal (arising above the dentate line) or external (below it), and are extremely common – 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 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 / 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 it under sensitive anoderm, and become exquisitely painful when thrombosed. This is why painless bleeding points to internal piles, while sudden severe anal pain points to a thrombosed external pile or a fissure – not to uncomplicated internal haemorrhoids. |
Source: NICE
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