Haemorrhoids (Piles) : A Common Problem of Community.

Dilatation of anal cushions are called haemorrhoids. They also called piles. It is a common problem of community. Constipation, chronic straining, obesity and previous childbirth may lead to development of symptomatic haemorrhoids. An increase prevelance is seen amongst higher socioeconomic groups.

The classical position of haemorrhoids are 3, 7 and 11 o'clock which corresponds to branches of the superior haemorrhoidal artery. Haemorrhoids (Piles) is a common problem of community.

If they confined to the tissue of the upper anal canal then called internal haemorrhoids. If they extend to the tissue of the lower anal canal then called external haemorrhoids.

Symptoms of haemorrhoids are

1. Bleeding per rectum

• Bright red in colour 
• Not mixed with stool 
• Drop by drop or like spray after defecation
• Painless. 

2. Prolapse

• Intermittent lump appearing at the anal margin
• Usually after the defecation
• May reduce spontaneously
•  May require manual reduction.

3. Soiling

4. Mucous Discharge

5. Itching

6. Pain (Particularly when thrombosed or prolapsed with ulceration and inflamation)       

Inspection of perianal area for sentinel skin tags, anal fissures, rectal polyps and tumours. Then perform Digital Rectal Examination (DRE) and Proctoscopy.

DRE is done to feel any rectal growth or polyp.

Proctoscopy is done to confirm the presence of haemorrhoids.

Classification of Haemorrhoids

• First degree.  Only bleeding per rectum.
• Second degree. Bleeding and prolapse which reduce spontaneously.
• Third degree.  Bleeding and prolapse on straining and manual reduction is required.  
• Fourth degree. Bleeding and persistent prolapsed.

Complications of Haemorrhoids are 

• Strangulation 
• Thrombosis
• Ulceration
• Gangrene
• Fibrosis
• Portal pyaemia
• Severe haemorrhage leads to anaemia.

Treatment of Haemorrhoids

Malignancy must be ruled out in elderly patients before the treatment started.

1. Symptomatic Treatment

• Avoidance of constipation and straining by the use of stool softener laxatives and bulking agents.

2.  Injection Sclerotherapy (Mitchell)

• Submucosal injection of the sclerosant (5% phenol in almond oil).
• For first or second degree haemorrhiods whose symptoms are not improved by conservative measures.
• 5 ml of sclerosant is injected in to the apex of the each pile pedicle and reassessed the patient after the period of eight weeks, if necessary then injections are repeated.
• Causes submucosal fibrosis and fixation of the overlying mucosa.
• Pain when needle of injection is in the wrong place and should be withdrawn.
• Superficial ulceration when injected too superficial.
• Prostatitis, pelvic sepsis, impotence and rectovaginal fistula when injected too deeply.

3. Rubber Band Ligation

• Most common OPD procedure.
• For first and second degree haemorrhiods.
• Applied above the base of the haemorrhiods.
• Two haemorrhoids at a time can be ligated.
• Causes ischaemic necrosis of piles.
• Slough off within ten days.
• Pain, urinary retention and rectal bleeding are complications.

4. Cryotherapy (Lloyd Williams) & Infrared Photocoagulation (Leicester) Techniques

• Work on same principles as rubber band ligation and sclerotherapy.
• Higher recurrence rate 
• Now a days not often used.

5. Haemorrhoidectomy

Indications for Haemorrhoidectomy

• Third and fourth degree haemorrhiods.
• Second degree haemorrhiods that not cured by non- operative treatment.
•  Fibrosed piles.
• Intero-external haemorrhiods with well defined external haemorrhiods.
• Haemorrhiodsal bleeding which sufficient to cause anaemia.

Types of Haemorrhoidectomy

• Milligan-Morgan procedure (Open haemorrhoidectomy) is the most commonly used.
• Ferguson  procedure (Closed haemorrhoidectomy).
• Diathermy haemorrhoidectomy.
• Ligasure haemorrhoidectomy.
• Stapled haemorrhoidopxy (is becoming popular now a days). 

Complications of Haemorrhoidectomy

• Pain, acute retention of urine and reactionary haemorrhage are early complications.
• Secondary haemorrhage, anal stricture, anal fissure, infection and incontinence  are late complications.