Haemorrhoids

Note that this page is for patients with suspected or confirmed haemorrhoids as the primary diagnosis. It is not a rectal bleeding or suspected lower GI cancer  pathway (see colorectal service).

Initial Primary Care Management 

• The NICE CKS Haemorrhoids - summary  provides a concise and helpful agreed description of aetiology and classification.
• Emphasis is on lifestyle modification and conservative management, with only a minority requiring intervention. Lifestyle measures should continue to prevent recurrence even after intervention. 
• Classification, diagnosis and early management is covered on the accompanying 'Primary Care Management page'.

Outpatient Clinic interventions:

• Haemorrhoidal banding is a relatively straightforward procedure which can be done in the surgical outpatient clinic and can be performed alongside endoscopic evaluation. Banding does not usually require any bowel preparation. It takes 5 minutes to perform. There is a variable reaction by the individual. It can cause profound visceral pelvic pain or perianal pain which can last for 5 days following the procedure. Simple analgesics can be taken before and after procedure. We would recommend patients do not plan extensive activities for the 24 hours following banding. Bleeding can also be experienced for 5 days following the procedure
• NHS Tayside does not currently offer sclerotherapy or infra-red coagulation.

Operative interventions:

• Indication for operative intervention include haemorrhoids affecting quality of life which have not responded to conservative or clinic intervention (banding) or patients who cannot tolerate clinic intervention
• Total Haemorrhoidal Artery De-arterialisation (THD) is a procedure where the haemorrhoids are sutured under ultrasound guidance under usually general or spinal anaesthesia. It is usually a day case procedure and can cause pain for up to one week following the procedure. It can also cause bleeding. Advantages include the relatively low risk profile of the procedure and it can be repeated if necessary.
• Haemorrhoidectomy is a procedure where haemorrhoids are excised either using an electrocautery device or by standard excision. This is a useful adjunct for external haemorrhoids. It can also cause bleeding and pain but has the additional risk of injury to the sphincter muscle and subsequent problems with continence.
• Other procedures such as stapled haemorrhoidectomy are not routinely used in NHS Tayside.

Follow up
Follow up is usually done for those who are banded in the clinic environment to make sure that there has been resolution in symptoms and further treatment is not required. This would often be via a telephone appointment.
Patients may be offered an open appointment if that is deemed appropriate.

Refer to secondary care for further investigation and management:

• Patients with clinical diagnosis of piles who have not responded to initial conservative management. As a guide we recommend a 'pragmatic' initial treatment period of 6 weeks (time for lifestyle and conservative measures to embed)
• People with recurrent symptoms who do not respond to primary care management 
• Diagnostic doubt 
• Patients with a positive qFIT test should first be referred to the colorectal service for investigation as haemorrhoids are unlikely to cause a positive qFIT test. If referral for surgical intervention is required this can take place after they have first been investigated by the colorectal service to exclude other pathology.

Emergency presentations
Thrombosis of haemorrhoids usually presents with significant pain and a palpable/visible thrombosis. They do not need to be seen on clinic purely because they are thrombosed and are still best treated with conservative management of analgesia, stool softening, local anaesthetic gel can be useful along with ice and salt. Thrombosis of haemorrhoids will usually settle with these measures alone and there is no evidence to suggest operative intervention will assist this.

Management of persistent haemorrhoids following an acute episode, should proceed as previously outlined.

Where there are doubts about the need for admission this can be discussed with the General Surgical Registrar on-call (Ninewells)

Patients where a primary diagnosis other than haemorrhoids is suspected e.g. where the blood is mixed with stool, there is repeated rectal bleeding without an obvious anal cause, or patients wioth confirmed piles and a positive qFIT test. These should be referred  to the colorectal service for investigation.

For an outpatient clinic appointment refer via SCI Gateway - General Surgery - Lower GI. 
Should you wish advice you can contact us via SCI Gateway Advice Referral or General Surgical Registrar on-call at Ninewells if URGENT.

Should you wish advice you can contact us via a SCI Gateway advice referral (or Surgical Registrar on-call if URGENT).

FIT in rectal bleeding - results of NICE study. 

NHS Inform - Patient information leaflet - haemorrhoids

References
BMJ Best practice – Haemorrhoids. Thaha, M; et al. https://bestpractice.bmj.com/topics/en-gb/181.

European Society of ColoProctology: Guideline for Haemorrhoidal Disease. Van Tol, RR; et al. Colorectal Disease 2020. The Association of Coloproctology of Great Britain and Ireland. 22, 650-662. https://onlinelibrary.wiley.com/doi/epdf/10.1111/codi.14975.

Using the faecal immunochemical test in patients with rectal bleeding: evidence from the NICE FIT study. Hicks, G; et al. Colorectal disease 2021; 00; 1-9.

Measurement of faecal haemoglobin with a faecal immunochemical test can assist in defining which patients attend primary care with rectal bleeding require urgent referral. Digby, J; et al. Annals of Clinical Biochemistry 2020, 57(4); 325-327.

NICE guidelines for haemorrhoids. 2016. https://cks.nice.org.uk/topics/haemorrhoids/