• External (below dentate line; covered with skin)
  • Internal (above dentate line; covered with mucous membrane) 

External hemorrhoids

  • External haemorrhoids relate to venous channels of the inferior haemorrhoidal plexus
  • They are not true haemorrhoids; Commonly termed as perianal hematoma
  • Usually only recognised as a result of a complication, which is most typically a painful solitary acute thrombosis
  • They are best thought of as being external extensions of internal haemorrhoids.
  • Sudden onset, olive shaped, painful blue subcutaneous swelling at the anal margin
  • If the patient presents within 48 hrs, the clot may be evacuated under LA
  • If untreated, in majority of the cases, resolution or fibrosis occurs
  • This condition has been called ‘a 5-day, painful, self-curing lesion’ 

Internal haemorrhoids

  • Internal hemorrhoids are characteristically seen in 3, 7 and 11 o’clock positions
  • Nature of bleeding is characteristically separate from the motion and is seen either on the paper on wiping or as a fresh splash on the pan
  • Pain is not commonly associated with bleeding
  • Secondary internal haemorrhoids arise as a result of a specific condition (most important – anorectal cancer) 

Four degrees of hemorrhoids

First degree – bleeding only, no prolapse

Second degree – prolapse, but reduce spontaneously

Third degree – prolapse and have to be manually reduced

Fourth degree – permanently prolapsed


  • Non-operative: Sitz bath
  • First or second degree piles not relieved by conservative measures – sclerotherapy-using Gabriel’s syringe (submucosal injection of 5% phenol in arachis or almond oil in the apex of the pile pedicle)
  • For more bulky piles – banding(Barron’s bander)
  • Hemorrhoidectomy – for third and fourth degree piles, fibrosed hemorrhoids
  • Secondary hemorrhage occurs usually on the seventh or eighth day

 v  Jack knife position (prone position with buttocks elevated) – pilonidal sinus excision

Exam Question

  • Pain of External hemorrhoids is carried by Pudendal Nerve.
  • Internal Hemorrhoids is ideal for the treatment with injection of sclerosing agents.
  • Hemorrhoids is the most common cause of fresh lower gastointestinal bleed in India.
  • A jaundiced, 43 year old alcoholic male presents to the emergency room complaining of bright red blood in his last two stools. He denies pain on defecation or changes in his bowel habits. Hemorrhoids would be the most likely finding on sigmoidoscopic examination.
  • External hemorrhoids below the dentate line are painful.
  • Five-day self subsiding pain is diagnostic of thrombosed external hemorrhoids.
  • Hemorrhoids are probably the most common cause of Lower GI Bleed .
  • MC complication following hemorrhoidectomy is Urinary retention.
  • Treatment of choice for 3rd degree hemorrhoids is Hemorrhoidectomy.
Don’t Forget to Solve all the previous Year Question asked on Hemorrhoid

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