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Haemorrhoids are enlarged or changed tissue in the lower re**al and a**l area. Usually both connective tissue and vascular elements are involved, which explains why haemorrhoids can lead to local discomfort and bleeding.

Haemorrhoids can be classified as external haemorrhoids and internal haemorrhoids.

Internal and external haemorrhoids will usually present differently, explains Dr Tillmann Jacobi.

External haemorrhoids always feature a prolapse which is typically very painful

There are four different degrees depending on if they are prolapsing.

GRADE 1 PILE: these are small inflammation and swelling in the a**s, they are not always visible but you Feel it

GRADE 2 PILE: at this stage it graduates to a small swelling that only comes out drunk lung stooling but it goes back unaided!

GRADE 3 PILE: this is the grade where they are visibility outside the a**s and you feel them, but can easily be pushed back.. this stage is very dangerous!

GRADE 4 PILE: This is the stage where the doctor advises a surgery because you are at a risk of a**l cancer!

Haemorrhoids can also be distinguished in terms of their occurrence as an isolated problem, intermittent-episodic or chronic. The majority of adults in the western world experience some haemorrhoidal symptoms at some point during their life, but only few will require medical help.

1. Risk factors
Haemorrhoids are uncommon in children but a frequent problem in adults with an almost equal distribution among men and women. Risk factors include pregnancy or other causes of increased intra-abdominal pressure, suboptimal diet with low fibre intake and increased risk of constipation or straining or even chronic-intermittent diarrhoea.

A strong family history will also increase the likelihood of haemorrhoids.

2. Clinical presentation
Internal and external haemorrhoids usually present differently. Internal haemorrhoids tend to cause painless bright-red bleeding, which is on the faeces but not mixed in. There can be local itching, soiling and blood on the toilet paper. In more advanced stages patients may notice a prolapse.

3. Assessment and diagnosis
When taking the history it is important to enquire about changes of bowel habit, type and duration of pain, significant family history, weight changes or fatigue and the colour and distribution of bleeding.

Changes to the diet, recent travels abroad and current occupation should be noted.

The physical examination includes the abdomen as well as the a**l area with digital re**al examination if this is not too painful. Note that haemorrhoids may empty with the pressure from the examination and therefore can appear much smaller than they actually are.

Important differential diagnoses of haemorrhoids include colore**al or a**l cancer, inflammatory bowel disease (ulcerative colitis and Crohn's disease) and diverticular disease. Sometimes a**l fissures, fistulas, warts or ulcers and polyps are the cause for the a**l discomfort. Also, local infection or inflammation (thread worms, contact dermatitis) can resemble the symptoms of haemorrhoids.

4. Management
Management will be determined by the clinical findings, the severity and duration of symptoms and the risk of any potentially serious differential .

Cases with severe pain, third or fourth degree internal haemorrhoids (not easily reducible) and patients with a possible systemic condition, such as inflammatory bowel disease, should be referred
If the haemorrhoids are caused by pregnancy they may likely resolve after delivery. If not please seek early treatment

Conservative treatment of haemorrhoids with topical ointments and suppositories are generally safe and useful in most mild to moderate cases.

However, long-term use of local anaesthetics or steroids should be discouraged.

External haemorrhoids, which cause mild to moderate pain, can be managed conservatively

Patients should be advised that recurring symptomatic haemorrhoids can be prevented through increasing fibre intake.

However, a sudden increase of fibre intake can cause considerable bloating and bowel upset and may not be appropriate for all patients.

Taking fibre-based laxatives might be more feasible and is generally quite effective.

Key Points
Haemorrhoids sometimes are due to lifestyle and diet.
Mild to moderate cases of both internal and external haemorrhoids usually respond well to conservative treatment.

A detailed history and appropriate examination is essential to decide on the need for further investigations.
Prevention of recurrence is an important part of management.