The American College of Gastroenterology (ACG) updates discussed in this article highlight the condition of haemorrhoids based on its severity and the management protocol that it requires.

Internal haemorrhoids are associated with painless bleeding and intermittent protrusion. The diagnosis depends on the exclusion of other conditions that can produce similar symptoms. Dietary modification consisting of adequate fluid and fibre intake and counselling to minimise straining at defecation should be first-line therapy for symptomatic haemorrhoids.

Types of haemorrhoids

Symptomatic haemorrhoids are characterised by painless bleeding or protrusions through the anal verge during or after the process of defecation. Based on the degree of protrusion, internal haemorrhoids can be categorised as below:

• Grade 1 haemorrhoids - Not associated with prolapse
• Grade 2 haemorrhoids - Prolapse with straining and spontaneously reduce after a bowel movement
• Grade 3 haemorrhoids - Prolapse and need manual reduction
• Grade 4 haemorrhoids - Prolapse and are not manually reducible

Internal haemorrhoids

Internal haemorrhoids occur as a result of loss of connective tissue support and prolapse, which makes them more prone to trauma from straining and/or the passage of hard stools. Constipation and prolonged sitting on the toilet can contribute to the development and symptoms of internal haemorrhoids.

External haemorrhoids

External haemorrhoids are located distal to the dentate line and are covered by squamous epithelium. External haemorrhoids are usually painless, but they can be painful when they develop an acute thrombosis. External haemorrhoids may become thrombosed by developing a clot in a vein under the squamous epithelium of the anal verge. Such haemorrhoids are termed thrombosed external haemorrhoids. Thrombosed external haemorrhoids present with sudden onset of pain and swelling that may be external to the anal verge or just inside the anal verge.

Clinical features of haemorrhoids

The main signs of internal haemorrhoids are:

• Haemorrhoid-pattern bleeding which can be defined as painless bleeding with bowel movements. In this case, it is important to rule out other sources of bleeding and protrusion
• Intermittent, reducible protrusion

The main signs of external haemorrhoids are:

• Painful swelling
• Painless anal skin tags, which represent residual redundant skin from previous episodes of inflammation and thrombosis

Treatment recommendations for haemorrhoids

1. Dietary modification consisting of adequate fluid and fibre intake and counselling to minimise straining at defecation should be the first-line therapy for symptomatic haemorrhoids
2. Patients with acutely thrombosed external haemorrhoids may benefit from either surgical excision or incision and evacuation of the thrombus when seen within the first 4 days.

3. Symptomatic grade 1 and 2 internal haemorrhoids that fail medical therapy can be effectively treated with office-based procedures such as a rubber band ligation. Alternative procedures include infrared coagulation, sclerotherapy, and bipolar coagulation.
   1. Symptomatic first- and second-degree haemorrhoids which do not respond to conservative management can be treated in the office with rubber band ligation, a popular and effective office treatment for internal haemorrhoids. Rubber band ligation is a simple procedure with low complications. The procedure can be easily repeated if symptoms recur.
   2. Apart from rubber band ligation, infrared coagulation, sclerotherapy, or bipolar coagulation can be used. Infrared coagulation and sclerotherapy are good options to treat bleeding haemorrhoids that are too small to ligate.
   3. Sclerotherapy is successful in treating patients with first- to third-degree haemorrhoids –almost 75% to 90% of patients are said to benefit from this therapy. Though recurrence is frequent with sclerotherapy, retreatment is considered safe and complications are similar to ligation. Sclerotherapy can be an effective option for patients with acute bleeding who are on anticoagulants or are immunocompromised.
   4. Infrared coagulation is most commonly used for first- and second-degree haemorrhoids. The procedure involves the contact application of infrared heat via a device inserted under vision through an anoscope. Using the infrared heat, the procedure cauterizes the base of the haemorrhoid.
4. Doppler-guided procedures such as haemorrhoidal artery ligations have similar outcomes to hemorrhoidectomy for symptomatic grade 3 haemorrhoids.
   1. Doppler-assisted hemorrhoidal artery ligation involves the use of a Doppler-equipped anoscope to identify and ligate the arteries which flow through the internal haemorrhoids. This procedure is followed by a haemorrhoidopexy or a rectoanal repair.
   2. Symptomatic grade 3 haemorrhoids may be treated with Doppler-guided hemorrhoidal ligation with a hemorrhoidopexy, mucopexy, or a stapled hemorrhoidectomy. Doppler-guided hemorrhoidal ligation is not an option to treat the external component of fourth-degree haemorrhoids.
   3. The main benefit of Doppler-assisted haemorrhoidal artery ligation is that no tissue is excised. On the other hand, stapled hemorrhoidectomy has been shown to have a higher complication and long-term recurrence rates. Due to this reason, stapled hemorrhoidectomy has been less frequently used as a treatment alternative.
   4. For grade 4 haemorrhoids, traditional hemorrhoidectomy is the recommended treatment option.
   5. Thrombosed external haemorrhoids may be treated surgically if seen within 4 days. The surgery involves the excision of the clot with the removal of overlying skin to prevent a recurrence. Conservative approaches to treat thrombosed external haemorrhoids include softening the stool with docusate, sitz baths, and pain control. Conservative approaches are effective but may take a longer time for symptom relief and is associated with a higher recurrence rate.

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