CAUSES & TYPES
Hemorrhoids is one of the commonest disease in the western world and is also seen commonly in India. Not many people like to talk about it hence true statistics in India are not available. In the west over half the population over the age of 50 suffer from it. However they can occur at any age and can affect both women and men.
Because the presence of pile tissue is normal, it acts as a compressible lining which allows the anus to close completely. Disease should be thought of as pile tissue that causes significant symptoms. Unfortunately, piles tend to get worse over time, and disease should be treated as soon as it occurs.
An exact cause is unknown; however, the upright posture of humans, forces a great deal of pressure on the rectal veins, which sometimes causes them to bulge. Other contributing factors include:
Chronic constipation or diarrhea
Faulty bowel function due to overuse of laxatives or enemas; straining during bowel movements
Spending long periods of time (e.g., reading) in the toilet
Irregular life style(working in shifts)
Patients on blood thinners like (Aspirin, Heart patients)
Whatever the cause, the tissues supporting the veins stretch. As a result, the veins dilate; Piles may be caused by more than one factor. Piles can be either internal or external, and patients may have both types. External piles occur below the dentate line and are generally painful. When inflamed they become red and painful, and if they become clotted, they can cause severe pain and be felt as a painful mass in the anal area. Internal piles are located above the dentate line and are usually painless. Dentate line is a line seen in the anal canal that demarcates the area with pain sensation from that without it. Piles that protrude into but do not prolapse out of the anal canal they are classed as grade I; if they prolapse on defecation but spontaneously reduce they are grade II; piles that require manual reduction are grade III; and if they cannot be reduced they are grade IV. Piles that remain prolapsed may develop thrombosis and gangrene.
DIAGNOSIS & INVESTIGATIONS
The diagnosis is made by examining the anus and anal canal, and it is important to exclude more serious causes of bleeding, such as cancer. No relation between piles and cancer has been found. A simple look inside is done by a procedure called proctoscopy where a 3 inch long hollow instrument with a diameter of about 1 inch is introduced in the rectum and with the help of a torch, the inside is looked at by the doctor. The procedure is painless and is done in the OPD.
Occasionally sigmoidoscopy and colonoscopic examination of the large intestine may be required if other diseases are suspected. these procedure are done under sedation or anaesthesia.
PREVENTION OF PILES
The best way to prevent haemorrhoids is to keep stools soft so they pass easily, thus decreasing pressure and straining, and to empty bowels as soon as possible after the urge occurs. Increased fibre in the diet helps reduce constipation and straining by producing stools that are softer and easier to pass. If the diet cannot be modified in this way, adding bulk laxatives may be necessary; they can prevent worsening of the condition. There are numerous creams and suppositories that can relieve anal irritation and pain, but they rarely provide long term benefit.
In addition, a person should not sit on the toilet for a long period of time.
The standards task force of the American Society of Colon and Rectal Surgeons states that surgery should be reserved for those who "fail more conservative measures" or who have "third and fourth degree piles" ... with severe symptoms.
Several operative techniques have been described. The surgeon's choice of technique is primarily based on personal experience and technical training, and only a competently performed technique produces satisfying results. If technical guidelines are rigorously followed, the feared complications associated with surgical procedures, such as anal narrowing and muscle injuries, are largely reduced. Furthermore, certain medicines suppress postoperative pain, increase patients' satisfaction, and allows them to return to work earlier.
Minimally Invasive Treatment
Studies suggest that Stapled Piles Surgery ( also known as PPH - procedure for prolapse and hemorrhoids or MIPH - Minimally invasive procedure for hemorrhoids ) is an effective treatment, reducing operative bleeding, postoperative pain, the length of hospital stay, and encouraging a rapid return to normal activities when compared with conventional piles surgery.
This technique potentially provides a tool for reducing some of the problems associated with conventional surgery. The pile masses are compressed into a cup like cavity inside the stapler. When fired, the staples cut and seal simultaneously, thus causing minimal bleeding and as the cut line is above the nerves, there is reduction in post operative pain. However, stapling increases operative costs.
Pain in advanced disease
Prolapse of piles
Skin tags and over growth at the anal verge
Itching and Discharge
Internal hemorrhoids cannot cause cutaneous pain, but they can bleed and prolapse. Prolapsing internal hemorrhoids can cause perianal pain by causing a spasm of the sphincter complex. This spasm results in discomfort while the prolapsed hemorrhoids are exposed. The discomfort is relieved with reduction. Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes concomitant external thrombosis. External thrombosis causes acute cutaneous pain.
Out Patient Procedures
For patients with grade I or grade II piles or who have larger piles but wish to avoid surgical treatment, outpatient procedures, such as sclerotherapy, Laser (IRC), band ligation, and cryotherapy, may be appropriate. It gives very good results with no side effects. These procedures are painless. Do not need more then 30 minutes in the clinic. These procedures are called office treatment in the western world, meaning you come from your office during the break, get the treatment done and go back to your office.
Laser (The infrared coagulator /photocoagulation) is for outpatient treatment of internal first and second degree piles. A special bulb provides high intensity infrared light that coagulates vessels and tethers the lining to subcutaneous tissues. it is the most effective non surgical treatment modality.
Injection Sclerotherapy is usually indicated in first and second degree lesions. it gives good results. it can be also done in patient with advance diseases.
The least expensive and possibly the most widely used equipment is a rubber band ligator. This is suitable for first to third degree piles. Rubber band treatment works effectively on internal piles that protrude during defecation. The procedure sometimes produces mild discomfort and bleeding, but it is generally the treatment of choice for patients who have piles and for whom piles surgery is considered too radical, or when the patient specifically wishes to avoid surgical excision.
Cryotherapy is little used because of the profuse and prolonged discharge, the complications such as excessive sloughing and muscle injury that occur occasionally.
Hemorrhoidal Arterial Ligation (H.A.L.) is performed using a modified proctoscope in conjunction with a Doppler ultrasound flowmeter.
Symptoms are due to prolapse, thrombosis, and vascular bleeding; therefore, creams have little role in treating hemorrhoidal complaints.
Bathing in tubs with warm water universally eases painful perianal conditions,as it causes relaxation of the sphincter mechanism and decreases spasm.
Bulk laxatives and treatment of bowel infection. Many patients see improvement or complete resolution of their symptoms with the above conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after one month of conservative therapy.
Treatment is directed solely at symptoms and not at the hemorrhoids' appearance. Many patients have been referred for surgery because they have swollen prolapsed hemorrhoids or large external skin tags. When questioned, the patients are asymptomatic. It has been said, "You can't make an asymptomatic patient feel better." Treat hemorrhoids only if they cause problems. Similarly, patients often ask when they should have surgery. Remind them that their hemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome and are not responding to non operative treatment. At our centre more then 90% patients are treated without surgery and have very good long term results.
The treatment choices for piles include :
Infra Red Coagulation (IRC)
Cryosurgery (cold probe)
Rubber band ligation
Scalpel (standard) surgery
The clear advantages of the modern methods for outpatient treatment of internal piles are that they are quick and relatively painless. Patients lose little if any time from work, the complications are minor, and the cure rates are high. Pain is minimal.
Patients may have a little spotting of blood for a few days and slightly more bleeding may occur after 10-14 days, when the eschar sloughs, but major bleeding do not occur as in the old style surgical approaches. No episodes of infection, death, or impotence have been reported with the newer methods. The failure rates are reported to be 1-5%, but all that is needed is further treatment.
Formal surgical intervention is still occasionally necessary, but patients dislike it because of the associated pain and morbidity. Modern treatment methods provide a prompt effective treatment in most cases.