High-yield map
Key points before the detail
- 01
Haemorrhoids are symptomatic descent/enlargement of normal anal cushions, not simply varicose veins.
- 02
Painless bright-red bleeding and prolapse are typical; severe pain suggests another process.
- 03
Goligher grade describes prolapse, not overall severity.
- 04
Rubber-band ligation is the principal office treatment for persistent internal disease.
- 05
Persistent bleeding still requires appropriate colorectal cancer assessment.
1. What haemorrhoids are
| Structure | Clinical meaning |
|---|---|
| Internal cushions | Above dentate line; bleeding and prolapse are common, sharp pain is not. |
| External/perianal thrombosis | Below dentate line under pain-sensitive skin; acute thrombosis is very tender. |
| Anorectal varices | Portal hypertensive collaterals; not the same disease as haemorrhoids. |
2. Goligher grading
| Grade | Prolapse behaviour |
|---|---|
| I | Bleeds without prolapse beyond anal canal. |
| II | Prolapses on defecation and reduces spontaneously. |
| III | Requires manual reduction. |
| IV | Permanently prolapsed or repeatedly incarcerates. |
3. Typical symptoms and red flags
- Painless bright-red bleeding during or after defecation.
- Prolapse, mucus leakage, pruritus and hygiene difficulty.
- Pain suggests thrombosis, incarceration, fissure, abscess or another diagnosis.
- Blood mixed through stool, altered bowel habit, iron-deficiency anaemia, weight loss, a mass or persistent symptoms require broader investigation.
4. First-line treatment
- Increase fibre gradually and use laxative support when stool remains hard.
- Avoid straining and prolonged toilet sitting.
- Use non-opioid analgesia and short-term topical symptom relief when needed.
- Treat the patient’s dominant symptom rather than trying to remove all normal cushion tissue.
5. Office procedures
| Procedure | Best use | Caution |
|---|---|---|
| Rubber-band ligation | Persistent grade I–II and selected III internal disease. | Band must be above dentate line; warn about delayed bleeding and rare pelvic sepsis. |
| Injection sclerotherapy | Bleeding-predominant smaller internal disease. | Less effective for substantial prolapse. |
| Infrared coagulation | Small grade I–II bleeding disease. | May require repeat treatment. |
6. Operative treatment
| Operation | Strength | Trade-off |
|---|---|---|
| Excisional haemorrhoidectomy | Durable for large III–IV prolapse or external component. | More postoperative pain; bleeding, stenosis and continence risks. |
| Haemorrhoidal artery ligation/dearterialisation with mucopexy | Less tissue excision and often less early pain. | Recurrence/persistent prolapse may be higher. |
| Stapled haemorrhoidopexy | Less early pain in selected circumferential mucosal prolapse. | Important long-term recurrence and rare severe pelvic complications; not default. |
Active recall
Close the notes and answer these
Try each question from memory before revealing the answer. These public prompts are a small preview of the integrated retrieval system inside SurgAtlas.
01Are haemorrhoids simply varicose veins?
No. They are symptomatic enlargement/descent of normal anal cushions.
02What does Goligher grade measure?
The behaviour of internal haemorrhoidal prolapse.
03What symptom is atypical for uncomplicated internal haemorrhoids?
Severe sharp pain; this should prompt consideration of thrombosis, fissure, abscess or another diagnosis.
04Where must a rubber band be placed?
Above the dentate line.
05Do visible haemorrhoids exclude colorectal cancer as a cause of bleeding?
No.
Sources & editorial basis
References & editorial basis
- SurgAtlas production source. General Surgery — Haemorrhoids. Public lesson curated from the corresponding production chapter.
- ESCP guideline. European Society of Coloproctology guideline for haemorrhoidal disease, as recorded in the SurgAtlas source register.
This lesson is derived from the corresponding SurgAtlas production teaching material. Where the source makes current management or guideline claims, the public lesson uses the cited contemporary guidance. It is written for education and examination preparation, not as patient-specific clinical advice.
Editorial details
Medical Doctor (MD) · MRCS Part A · Physician · Surgical Educator
SurgAtlas is an educational resource. For patient care, verify current national guidance, local antimicrobial and transfusion policies, specialty pathways and individual patient factors.
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