Piles: Dos and Don’t | Types of Piles & Treatment of Piles

Piles are also called Haemorrhoids. Haemorrhoids are masses of dilated blood vessels that lie beneath the lining of skin in the anal canal. It is a perianal varicose vein or the dilated portion of the vein in the anal canal.

Types of Piles

Piles are classified into two types:

  1. Internal haemorrhoids
  2. External haemorrhoids

Internal haemorrhoids: those that occur above the anal sphincter are classified as internal haemorrhoids.

External haemorrhoids: those that occur below the anal sphincter are classified as external haemorrhoids.

Incidence

Piles are a common disorder affecting both men and women of any age. The incidence is increased between 20-50 years of age.

Aetiological factor

The exact cause remains unclear or unknown but contributing factors are:

  • Hereditary (rare)
  • Congenital weakness of the vein wall or
  • Abnormally large arterial supply to the rectal plexus
  • Recurrent constipation/ diarrhea
  • Staining accompany: constipation
  • Persistent elevation in intraluminal pressure
  • Pregnancy, obesity, heavy lifting
  • Congestive heart failure and chronic liver disease resulting portal hypertension (increase venous pressure)
  • A sedentary lifestyle involving long periods of sitting or standing
  • Ageing, prostate enlargement in males
  • Excessive use of enemas or laxatives

Pathophysiology

Internal haemorrhoids

Haemorrhoids are developed as a result of shearing force during defecation or straining during a bowel movement increases intrabdominal and hemorrhoidal venous pressure. These force or pressure damage the supporting muscles resulting weaken and dilated anal canal. When the rectal ampulla is filled with stool, venous obstruction is believed to occur, as a result of the repeated and prolonged increase in thin pressure, hemorrhoidal veins become permanently dilated. These causes impaired blood flow through the vein of hemorrhoidal plexus. As a result of distension thrombosis and the bleeding also may occur.

External haemorrhoids

Varicosities of veins draining the territory of inferior rectal arteries which are branches of internal pudendal artery itching due to skin irritation prone to thrombosis, of vein rupture and /or a blood clot develops. It is thrombosis haemorrhoids.

Clinical features

  • Internal haemorrhoids
  • Asymptomatic
  • Painless, intermittent bleeding during defecation
  • When internal haemorrhoids become constricted patient may report pain
  • When internal haemorrhoids become prolapsed and strangulated there is a pain
  • External haemorrhoids
  • Visible bluish skin covered lumps in the anal region
  • If blood clots in external haemorrhoids become inflamed oedematous and painful
  • Intermittent pain, pain on palpation, itching and burning
  • Rectal bleeding associated with defecation (patient may complain)
  • Extremely itching around the anus
  • Irritation and pain around the anus area
  • Faecal leakage or incontinence
  • Painful bowel movements
  • Blood on the tissue after having a bowel movement

Diagnosis

Haemorrhoids are typically diagnosed by physical examination. A visual examination of the anus and surrounding area help to diagnose external or prolapsed haemorrhoids.

Internal haemorrhoids

It originates above the dentate line. They were classified in 1985 into four grades based on the degree of prolapse.

  • Grade I: No prolapse, just prominent blood vessels
  • Grade II: Prolapse upon bearing down, but spontaneous reduction
  • Grade III: Prolapse upon bearing down requiring manual reduction
  • Grade IV: Prolapse with an inability to be manually reduced

External haemorrhoids occur below the dentate line.

  1. Proctoscopy: to confirm internal haemorrhoids (visual inspection of an anus, digital palpation with a gloved lubricated finger)
  2. Lab investigation: CBC including electrolytes
  3. Sigmoidoscopy or colonoscopy to rule out other cause of disease

Management

  1. Local or conservative management
  2. High fibre diet and increased fluid intake
  3. Warm sitz  bath given several times or day to relief pain
  4. Application of cold and hot (topical nitroglycerin may also be used )
  5. A stool softener is given to decrease the irritation of haemorrhoids
  6. Analgesic ointment application (with hydrocortisone) to relieve pain and reduce oedema

Surgical management

  1. Sclerotherapy: it is performed by the injection of a sclerosing agent. It causes a formation of scar tissue between around the veins. This produces an inflammatory reaction that leads to thrombosis and fibrosis causing shrinkage of pile mass.
  2. Ligation (rubber band): haemorrhoid is ligated with a rubber band which becomes necrotic and slough off due to impaired circulation.
  3. Cryosurgery: freezing of hemorrhoidal tissue leads to necrosis and sloughing of haemorrhoids
  4. Infrared coagulation: infrared rays is used to burn the haemorrhoid tissue
  5. Laser treatment: the haemorrhoids is burned off with a very thin beam of light in which very high energies are concentrated (laser). There is minimal bleeding although the procedure causes some pain.
  6. Bipolar diathermy: heat production of high-frequency electric current passed between two electrodes placed on the patient skin.
  7. Hemorrhoidectomy: the vein is excised and the area either is left open to heal by granulation or is closed with sutures. The open method is very painful but has a high rate of success. The suture method, although for less painful is more likely to cause infection and result in poor healing.

Home remedies

  • Maintaining good hygiene by cleaning anus area with warm water during a shower or bath every day.
  • Avoid using dry or rough toilet paper when wiping after a bowel movement.
  • Using a cold compress on anus can help to reduce haemorrhoid swelling.

Complication

  • Bleeding, thrombosis and hemorrhoidal strangulation
  • Iron deficiency anaemia from severe bleeding during defecation
  • Post-surgery haemorrhage, infection, stricture formation and the lesion heals

Haemorrhage may occur immediately after surgery or about 10 days later as a result of sloughing of tissue. Also, bleeding may not be evident because it can occur into the rectum without being passed immediately.

Prevention

  • To prevent or avoid worsening haemorrhoids, avoid straining during a bowel movement also try to increase the fluid intake which helps the stool from hardening.
  • Increase fibre diets help to prevent constipation.
  • Exercise regularly to prevent becoming constipated
  • don’t sit for long periods, especially on hard surfaces like concrete or tile
  • spending less time attempting to defecate
  • losing weight for overweight persons
  • avoiding heavy lifting

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