Haemorrhoids are swollen, distended veins in the rectum or anal canal. They usually remain inside the rectum but may protrude through the anal sphincter during exercise, or even, as in this case, on standing. They are divided into four grades — those that protrude on exercise, but spontaneously disappear when lying flat, are grade 2. They are common in people who do heavy work, who have given birth, or are chronically constipated and have to strain when they go to the lavatory.

The usual rule is for patients with grade 2 piles to have three attempts at banding, or injections to sclerose (block) the blood vessels. In banding, the root of the haemorrhoid is constricted by a rubber band. If successful, the haemorrhoid is starved of blood and shrivels. As banding treatment over three years hasn’t improved his situation, it may well be that surgery is now the answer.

Surgery has a reputation for causing gross discomfort. It is uncomfortable, but this is often exaggerated. The exaggeration of the discomfort, anxiety about possible complications and underestimating of the distress that piles may cause probably now result in the operation being carried out less often than it was, and still should be. Age is no bar to surgery. He may be off work for a fortnight. Possible complications include anal fissure, haemorrhage, anal stricture and transient urine retention.

A 44-year-old woman, who has a healthy life and diet, exercises, is slim and happily partnered, has endometriosis. When she has a period she has cramping abdominal pains, bloating, but also has cold-like symptoms, with nasal congestion, sneezing, headaches and depression.

It sounds trite to say that endometriosis is a strange condition, but so it is. The nasal symptoms are unusual, but few doctors haven’t come across them. Endometriosis occurs when the tissue that normally lines the uterus migrates and grows elsewhere. The migrant tissue may settle on the ovaries, the peritoneum (the bag that holds the abdominal contents), the pelvic organs, the small and large bowel, the vulva, abdominal scars and may even migrate to the lungs. When endometrial deposits are buried within uterine muscle, the condition is known as adenomyosis.

When a woman with endometriosis menstruates, not only does her uterine lining bleed, but so may the other deposits of uterine tissue. If the blood is trapped, a cyst, known as a chocolate cyst, forms. In order of frequency, endometriosis may give rise to abdominal pain and tenderness, including severe discomfort on intercourse, lower abdominal pain and other pelvic symptoms, infertility, menstrual irregularities, pain and/or bleeding on passing urine, constipation and rectal bleeding. If there are deposits in the lung, the woman may cough up blood.

The unusual feature is the association between the nasal lining and the uterus. It is said that a woman’s nasal lining may reflect that of the uterus. Pregnant women with this association may develop nasal congestion and, as may all women during sex, their noses may itch. If they have endometriosis, and therefore excessive uterine tissue, their noses may run during a period and cause symptoms like those of a cold. The sore throat may follow nasal congestion and mouth-breathing at night. Endometriosis disappears entirely at the menopause, whenever this may be. When symptoms are unbearable, treatment should be medical, surgical or a combination of both.

A 23-year-old athletic man, who sleeps well, is in good health, drinks little and is a non-smoker, is concerned because he often looks tired, weary and apparently wrinkled. Tests have shown that his only problem is Gilbert’s syndrome. What is it that makes him look so ill?

Gilbert’s syndrome, unconjugated hyperbilirubinaemia, is not a disease; it is a minor variation from the usual that affects up to 5 per cent of the population. It is the name given to a slight excess of bilirubin, the bile pigment, in the blood. The bilirubin level alters the way light is absorbed and reflected by the skin, so that someone with Gilbert’s syndrome doesn’t have a standard healthy glow and often looks tired, even weary, when fit and vital.

When people with Gilbert’s are slightly ill or overtired, they may look absolutely knackered, and may then derive more sympathy than is warranted. Some continental doctors “treat” Gilbert’s syndrome, but the only treatment necessary is reassurance that the patient doesn’t have liver disease.

E-mail Dr Thomas Stuttaford your questions on haemorrhoids

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