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Piles & Haemorrhoids

Piles

These guidelines apply to situations where the diagnosis of Haemorrhoids is likely or confirmed. For undiagnosed PR bleeding, see the “Rectal Bleeding” guideline.

Haemorrhoids are more likely when PR bleeding is associated with perianal symptoms such as soreness, discomfort, lumps, lumpiness or  itching,  prolapse and pain

Primary care management prior to referral:

Dietary and lifestyle advice (increase fluid and insoluble fibre intake, discourage straining, regular exercise, feet-up position: see http://www.evidentlycochrane.net/feet-up-constipation/?)

Bulk forming laxative (or osmotic laxative or stool softener)

topical haemorrhoid preparations for symptomatic relief

Perform a digital rectal examination. If too painful, consider alternate diagnosis such as anal fissure

When to consider referral:

The haemorrhoids are recurrent and associated with persistent bleeding or prolapse

And

There is failure of documented conservative management techniques after at least 6-8 weeks.

Or

Red flag symptoms present –  see 2 week wait referral guidelines

Or

If the haemorrhoids are prolapsed and incarcerated, and cannot be reduced (Fourth degree haemorrhoids)

Information required with referral

Details of prior therapeutic trials, including length of use of medications. Referrals will be cancelled if therapeutic trials are not complete and of an appropriate period of time, unless over-riding concerns are detailed.

Clinic options:

All referrals will be seen and assessed by the Colorectal Surgery team

 

 

 

Fissures

These guidelines apply to situations where the diagnosis of an anal fissure is confirmed in an adult. For undiagnosed PR bleeding, see the “Rectal Bleeding” guideline.

Anal fissures are most common at the posterior anal midline (90% females, 99% males). A “sentinel tag” may  be seen in association with a fissure parting the buttock cheeks if the fissure is chronic. It is usually too painful to perfom  a digital rectal examination. Anterior fissures are more likely to have occult external sphincter injury and impaired external sphincter function compared with patients with a posterior fissure.

Fissures outside of the midline can associated with crohn’s disease, and should raise clinical suspicion of this.

Anal fissures in the elderly are unusual. Please consider referral via the 2WW pathway (unexplained ulceration) Nicorandil may cause unusual perianal fissuring and ulceration and this should be considered

Anal pain may be caused by perianal sepsis which occasionally may be occult. If history is acute and suggestive, consider emergency referral

When to consider referral:

There is failure of documented conservative management techniques  at 6 weeks.

Primary care management prior to referral:

Almost half of acute anal fissures will resolve with conservative measures:

  • Dietary and lifestyle advice (increase fluid and insoluble fibre intake, discourage straining, regular exercise, feet-up position: see http://www.evidentlycochrane.net/feet-up-constipation/?)
  • Pain relief
  • simple analgesia (paracetamol/NSAIDs). Do not prescribe codeine as can constipate.
  • Sitz baths may be recommended
  • Short term (<1 week) 5% lidocaine or hydrocortisone preparations if pain extreme

If persistent:

  • GTN 0.4% ointment can be used for up to 8 weeks if no contraindications. Warn patients of common side effect of headache
  • Consider topical diltiazem 2%  which has a more favourable side effect profile (though unlicensed indication), particularly if GTN 0.4% not tolerated
  • Anal hygiene, keeping the area clean and dry

Information required with referral:

Details of prior therapeutic trials, including length of use of medications. Referrals will be cancelled if therapeutic trials are not complete and of an appropriate period of time, unless other concerns are detailed.

Clinic options:

All referrals will be seen and assessed by the lower GI surgical team