MANAGEMENT OF

Haemorrhoids (piles)

Haemorrhoids

VARIOUS CONDITIONS IN ANO RECTAL REGION

• Imperforate Anus• Piles• Fistula• Fissure• Ischio- rectal Abscess• Proctitis• Enlarged Pappila• Rectal Polyps / Warts• Pilo Nidal sinus• Carcinoma • Pruritis

Any Problem Around The

Anus Is Called As..

Piles

HAEMORROIDS (PILES) Definition : 1.These are the dilated veins within the anal canal in the sub-epithelial region formed by radicals of Superior, Middle and Inferior rectal veins. 2. Piles can be described as masses or clumps ("cushions") of tissue within the anal canal that contain blood vessels and the surrounding, supporting tissue (hemorrhoidal cushions).

Haemorrhoides Haima = blood Roos = flowing Piles Pila = ball

Anal cushions : These are submucus venous plexus containing arterial twigs, venules, smooth muscles, elastic tissue & connective tissue. Symptomatic anal cushions are called as piles / haemorrhoides.

INTRODUCTION & INCIDENCE

• Humans suffer from piles as a disadvantage of their erect posture.

• 50% of people over 50 yrs age suffer from some degree of piles.

• 30% of pregnant females suffer from piles

• Asymptomatic piles are found in many patients on routine examination

• Sex ratio approx. 2M : 1F

TYPES OF HAEMORRHOIDS • According to Symptoms- 1. Bleeding Piles 2. Non Bleeding Piles• According to Origin- 1. Hereditary – Pile mass is present by birth 2. Acquired – Pile mass developed after birth

• According to etiology- 1. Primary – Due to indulgence in unsalutary diets & habits 2. Secondary – Due to some other underlying disorders

• According to Location-

1. Internal Piles –It is covered with mucous membrane. It arise from Internal Hemorrhoidal plexus & above dentate line. 2. External piles – It is situated outside the anal orifice & is covered by skin. It arise from External Hemorrhoidal plexus & below dentate line 3. Internal + External – Combination variety can also co- exist & is known as Interno- External haemorrhoids.

Degrees of Internal Piles

1st-degreeProjects into anal lumen internally

2nd-degreeProtrusion outside anal canal at defecation with spontaneous reduction

3rd-degreeProtrusion outside anal canal at defecation straining – needs digital repositioning

4th-degree Permanently prolapsedirreducible piles

Positions of Piles

• PRIMARY Right anterior ( 11-o’clock) Right posterior ( 7-o’clock) Left lateral ( 3-o’clock)

• Accessory At every o’clock position

• DGHAL Arterial cushions at every odd o’clock position i.e. 1 / 3 / 5 / 7/ 9 / 11 o’clock

ETIOLOGICAL FACTORS• Congenital – This is due to ‘ Shukra- Shonit beej dosh. Pile mass is present by birth.

• Anatomical – The haemoroidal veins are situated in anal sub-mucosa in longitudinal direction & does not have support of any other surrounding tissue. So, being valve less structure (either due to any pressure/ obstruction on portal vein or due to gravity) they are always filled with blood which results in its dilatation, elongation & torsion.

• Alcohol – Excessive alcohol intake can cause Hepatitis resulting in portal hypertension which ultimately exert pressure on the haemoroidal veins resulting in protrusion of pile pedicle .

• Sedentary lifestyle – Long term sitting job, daily traveling for long distance, engaged in driving or abstinence from any kind of physical exercise may result in overfilling in the haemoroidal veins.

• Suppression of urge of daefication/ micturation: Suppression of urge of daefication vitiates vat which may result in constipation & further straining while daefication, exerting pressure on the haemoroidal veins. Similarly, frequent IBS or diarrhea may cause mucosal irritation & inflammation resulting in protrusion of pile mass.

• Asthma: Asthma or COPD is associated with vigorous & frequent coughing which increases the intra abdominal pressure, thus ultimately exerts pressure on the haemoroidal veins. Similarly, lifting heavy weight can also cause pressure on anal veins.

• Enlargement of Prostate: The male suffering from BPH usually strains while micturation & this forceful micturation exerts pressure on the haemoroidal veins. Similarly, patients suffering from urinary calculus & frequent UTI are also prone to such conditions.

• Other factors causing Piles:

In females-

1) During pregnancy the intra abdominal pressure is increased (due to the foetus) resulting in portal

hypertension. 2) At the time of labour (delivery) there is tremendous pressure on the anal canal causing anal fissure and prolapsed piles. 3) Fibroid in uterus may cause pressure on anal veins.

Some other factors mentioned in Sushrut samhita –

1) Straineous work (Balvad vigrah) 2) Anger or sorrowful emotions (Shok) 3) Contradictory food consumption (Adhyashan) 4) Over sex indulgence (Stri prasang) 5) Squatting posture (Utkatasan) 6) Horse riding (or long drive) 7) Suppression of natural urge (veg dharan) 8) Diminished Appetite (Mandagni)

SYMPTOMS

• Bleeding • Swelling / Prolapse• Straining / Pain / Discomfort• Constipation• Itching, Irritation• Incomplete evacuation• Digital evacuation /

instrumentation• Abdominal bloating = GAS

TROUBLE• Lethargy/ Wt. Loss• Black-out episodes• Symptoms of ANAEMIA

Pathogenesis of BleedingHard stools

Straining at defecation

Bruising of engorged venous cushions

De epithelization

Ulceration

Bleeding

Disruption of sinusoids by straining / irritation

Bleeding from pre-sinusoidal arteries

Constipation+Straining+IAS spasm

Venous back flow

Mucosal strech

Tear & Bleed

Bleeding

• Occasional to regular / recurrent

• Bright red ( from presinusoidal arterial twigs)

• Initally Streaks specially with hard stools

• Later Steady drip

• Advanced Squirts / stream / drip with defecation &

Also apart from defecation (blood spotting on undergarments)

Examination

• Gain the Confidence of the Patient

• Position

• Light (Angle- Poise Lamp)

• Instruments required like- Gloves, Jelly, Torch, Guaze,

Proctoscopes ,Forecep

Position of patient

• SIM’S position• Lithotomy position• Knee-Chest position• Prone position

What else is to be kept ready??

• Ears open• Eyes open• MIND open• Gentleness• Respect towards patient• Soft words & politeness• Understanding the patient

What thing to keep away

• Arrogance• Mobile phones• Sharp instruments• Ego

Foul thoughts

Wicked eyes

Inspection • Spread buttocks apart gently• Focus the light source• Observe the peri-anal region & anal verge

Skin discoloration Scars, Pruritus, Sinuses, Soiling, Discharge = Pus, Blood etc.

External Tag, Swellings (Boil/Induration) ? Sphincter Tone/Spasm (Refluxes)

Other Pathologies

Physical examination

• INSPECTION:

1ST-degree = Nil evidence

2nd-degree = Bogginess at anal verge at affected side, gentle traction on bogginess reveals mucosa

3rd-degree = Inner red/purplish mucosa & outer skin covered bogginess with linear furrow in between

4th-degree = Evident irreducible prolapse

• White Pannus• Pruritic signs• Soiled perineum

INSPECTION (Most neglected but most informative)

• Fissure• Hematoma• Wart• Pilonidal sinus• Pruritis ani• Prolapsed Piles• Sentinal pile / tag• Bleeding / Discharge

• External opening of fistula• Abscess• Sphincter tone• Soiling • Prolapse during valsalva• Stricture / Stenosis• Sphincter spasm• Worm infestations

D.R.E(DIGITAL RECTAL EXAMINATION)

P/R examination

Physical examination

D.R.E. (Digital Rectal Examination)

• Ask patient to bear down & gently insert lubricated gloved finger inside

• Early piles = Soft, easily collapsible venous swellings

• Late piles = Fibrosis of connective tissue Piles are palpable as soft longitudinal folds

Also appreciate : Anal tone Ano-rectal sling level Anal canal length .Squeeze pressure Inspect the finger for blood / mucus / feces Exclusion of other diseases esp. Ca’

PALPATION & DIGITAL RECTAL EXAMINATION (DRE)

Anal Canal Sphincter tone Ano-rectal sling Fibrosis Internal opening of Fistula Induration Tenderness.

Rectum Collapsed , ballooned Loaded / empty Wall irregularity & nodularity Stenosis / stricture Polyp / mass Cervix & uterus in females Prostate & seminal vesicles in males Blummer shelf deposits Examine the finger after P/R for

blood/mucus/pus/stools P.V. examination with separate gloves

Peri anal Tenderness,Peri anal Tenderness,IndurationInduration

ANOSCPOY / PROCTOSCOPY

• Proper instruments and lighting• Position• Technique• Many things can be diagnosed

Physical Examination –

With scope inside anal canal, ask patient to bear down & inspect while withdrawing the scope.

Look for = bulge – site / covering mucosa colourBleeding pointsRectal mucosa statusOther lesions

MANAGEMENT• Acute stage Conservative Treatment: In Allopath, the line of treatment is as follows –

1. In Acute stage i.e. if the patient comes with symptoms like severe pain with haematoma, then Analgesics+ Anti inflammatory + Anaesthetic agent like Xylocaine oint. / jelly is prescribed.

Also, patient is asked to take Hot Seitz bath with KMNO4. Haemostatic drugs like Stredron or Ethamsilate can be given to arrest bleeding

Generally, the swelling resolves itself. But if the condition do not improved, then it may suppurate or may fibrose giving rise to cutaneous tag or may burst giving rise to bleeding.

2. If haematoma do not resolve, then it is Incised under local anesthesia & the wound is allowed to heal by granulation tissue.

Conservative Management

• Diet – Fiber rich, balanced (easy to digest) diet

• Ointments - Hydrocortesone acetate,Heparin sodium, Aminobenzoate,Lignocaine hydrochloride, Zinc oxide

• Laxatives - Liquid paraffin, Lactulose, Isabgol, Senna,Castor oil, Bisacodyl

• Suppository- Bisacodyl,Glycerene

• Analgesics / Antibiotics / Prokinetics

• Oral preparations- Sodium picosulphate, Calcium dobesilate, Tranexamic acid

• Iron supplement

• Seitz’ Bath

Ayurvedic Management

Sushruta has mentioned four fold regimen for piles:

1. Aushadhi Chikitsa i.e Internal medicine effective in I and II grade piles

2. Kshar chikitsa i.e application of kshar locally or internally effective in I and II grade piles

3. Agni Karma i.e Excision of pile pedicle by Cauterization 4. Shalya Karma i.e Ligation and Excision of Pile pedicle

effective in III grade and prolapsed pile mass.

Ayurvedic Conservative treatment

– Deepan and pachan chikitsa The main objective is to restore the digestive power ( Jatharagni) by:

1. Ajmodadi churna or Hingavasthak churna2. Chitrakadi or ampachak vati3. Shankha vati ( form of mild kshar)

- Vata anuloman chikitsa For this purpose Avipatikar churna or Panchasakar churna can be prescribed

- Mal Sarak chikitsa-(To treat constipation) - Haritaki churna- Abhaya arishta - Triphala churna

To arrest bleeding Nagkeshar Churna, Bolbaddha ras or Kutaj Churna can be given.

Bhalatak kalp in non bleeding piles and kutaj churnafor bleeding piles is choice of drug mentioned in Sushrut.

Various combination for local application is advocated for initial stage like :

a. Latex of snuhi+ turmeric powder b. Kasisadi tailac. Turmeric podwer + Pippli churna+ Gomutra d. Nimbadi malhara etc.

• Specific guidelines mentioned in Sushrut Samhita

– In initial stage of piles local application of inform of lep is mentioned which may promote frbrosis and delay the protrusion of pile pedicle

• Snuhi latex + Turmeric powder can be tried • Turmeric + Pippali churna + Gomutra can be applied

– Specific instruction regarding Diet

• Shali, Shasti, Jau or wheat grain mixed with ghrit and milk and gruel is made.

This is to taken as diet regularly• Lot of green leafy vegetables• Shatavari mula kalka along with milk • Apamarga mula cooked with rice • Butter milk should be taken regularly

after food • Jaggery with haritaki

Kshar Karma in Piles

• This is indicated for II Grade internal piles. The kshar is applied to the dilated pile pedicles with the help of specially designed probe known as “Jambaushatha shalaka” under the guidence of proctoscope (Arsho darshan yantra) having slit on its side.

• After mild kshar application the pile pedicle is washed with sour gruel (Dhanyaamla) or water and followed by local application of yashtimadu ghrita at the site.

• Each pile pedicle is treated differently at the interval of one week.

• This may cause fibrosis of the tissues which prevents the pile pedicle from protrusion. Also to some extend it works similar to sclerosing therapy

Use of Kshar sutra in Piles• Some Ayurvedic surgeons prepare a separate kshar sutra which is mild in

nature and have less coatings for the ligation of internal pile pedicle. According to them this medicated Kshar sutra simultaneously necroses

the pile pedicle, and at the same time they promote fibrosis over the peripheral tissues.

• This technique is practiced in few places northern India and is not popular enough. • However this mild kshar sutra can be effectively used in external piles and external sentinel tags.

TREATMENT OPTIONS FOR PILES

NON-SURGICAL

(office procedures)

SURGICAL

BANDING SCLEROTHERAPY

I.R.C**

LASER**HAL

STAPLERM.I.P.H

OPEN**

CLOSED**

Harmonic

INJECTION SCLEROTHERAPY

HISTORY

1869= Jhon Morgan of Dublinintroduced this procedure using persulphate of iron

1871= Mitchell of Clinton-Illionis, USA, used carbolic acid (27–95%) & olive oil

HE SOLD THE SECRET TO QUACKS BEFORE HIS

DEATH

1879= Andrews of Chicago, discovered the secret from Quacks and gave it to the world.

Principle of Sclerotherapy

Injection of irritant solution evokes inflammatoryreaction in submucosa where haemorrhoidal vessels lie.

This results in 1) Encasement, which prevents defecatory trauma & thus prevents bleed

2) Blockage of hemorrhoidal vessels, which do not bulge on straining

3) Fibrosis, which fixes mucosa to muscle & prevents prolapse.

INDICATIONS FOR SCLEROTHERAPY

• INTERNAL PILES ONLY

BEST = for Grade – I, Bleeding Piles

GOOD = for Grade – II bleeding piles

PALLIATIVE = for Grade – III bleeding piles

Contra – Indications for Sclerotherapy

• External Piles

• Associated Anal Lesions eg; fissure, fistula, skin tags

• Attack of thrombosed internal piles

• Pregnancy

• Crohn’s / Ulcerative colitis

Solutions used for Injection:

PhenolVarious vegetable oils eg. Almond /

olive / coconut

STD (sodium tetradecyl sulphate)

Carbolic acid

Sodium morrhuate

Quinine & urea hydrochloride

Glycerine

Polidocanol

5 – 7ml (max = 10 ml)

1 – 2ml

Dosage per pile massper pile mass

Site of Injection

-In submucosa

-Into pile mass

- At the pedicle of the pile mass at ano- rectal ring (ALBRIGHT’S method)

Post-procedure Instructions

• Mild discomfort

• Tenesmus

• Follow – up after 3 wks

• Watch for fever / pain / bleeding.& inform sos

Advantage of Sclerotherapy

• Easily learned procedure

• Stops bleeding in 24 - 48 hrs in majority of cases• Cost – effective

• Office procedure so early return to work

• Painless

• Can be repeated

Complications of Sclerotherapy

• Fainting / Giddiness

• Necrosis

• Re-Bleed

• Abscess

• Stricture

• Urine retension

• Burning & itching

• Fistula formation

13/41

Injection Injection ulcerulcer

ParaffinomaParaffinoma

Results after Sclerotherapy

• Grade – I piles == 98 %

• Grade – II piles == 68%

• Grade – III piles == 31%

• Overall 77% successful

• Especially in stopping bleeding

• But has less effect on prolapsing element of pile

RUBBER BAND LIGATION (RBL)or

BANDING

Principle of RBL

• Rubber ring ligature applied to the mucosal covered part of the Internal Pile through a proctoscope

• This strangulates the feeding vessel to the pile and gradually cuts through the mucosa

• The pile thus sloughs off after 7 – 14days

Indication for RBL

• Ideal for Grade – II internal piles

• Early Grade -- III internal piles

Contra-indications• Bleeding diathesis (???)• Infection ( fistula / abscess)

• Fissure

Post – procedure Instructions

• Dull ache / fullness of rectum may be present

• Urge to defecate may be there

• Bleeding may occur ----- clots = 1-2days ----- spots = 5 – 14days

Follow-up after 2 weeks

Advantage of RBL

• No learning curve

• Effective symptomatic relief in 80 – 90% cases

• Safe procedure

• Virtually painless if done properly• Can band all 3 piles in one sitting

• Can be repeated after 3 weeks

• Cost – effectiveDISADVANTAGE OF RBL

Has no effect on skin covered componentComplications present ( avoidable )

Complication of RBL

• Pain Immediate / delayed

• Bleeding Immediate / delayed

• Thrombosis

• Fissure

• Slippage of band

• Sepsis

I.R.C.INFRA - RED COAGULATION

(Modified ‘Agnikarm’)

INDICATION FOR I.R.C.

• INTERNAL PILES ONLY

BEST = Bleeding Piles of Grade – I,

GOOD = Bleeding piles of Grade – II

15volt tungsten- halogen lamp

24 K Gold Plated Reflector

Solid Quartz Light Guide

Trigger Contac

t teflon tip

Light energy Heat energy

Principle of I.R.C.

• It causes actual burn upto the submucosa

• Light energy converted to heat energy

• Causes tissue destruction

• Evokes inflammatory reaction

• Results in scarring

Site of application:

Above the pile mass, At or just below A/R sling

( same as for sclerotherapy)

Pre-op instruction

Patient may feel slight warmth

ADVANTAGES• No operation• No bleeding• No pain• No anesthesia• No admission to hospital• No need to take leave from work• Safe for patients with Diabetes• Safe for patients with High Blood Pressure• Safe for patients with Heart Problems• Safe for Pregnant patients suffering from piles.

Cryo - Therapy

Principle :

Freezing the pile mass with cryo-probe to subzero

temperature of upto -700C with Nitrous oxide /

-1800C with Liquid Nitrogen Causing thrombosis of micro-

circulation & gradual necrosis and sloughing off of the pile.

• When cryoprobe is placed on the tissue the ice ball forms a visible white area which will eventually slough

• The procedure usually takes 10-15 min. and the patient is observed for 30 min.

Disadvantage of Cryo - Therapy

• Needs Local anesthesia / sedation

• Post-op pain present

• Copious foul smelling browny discharge for

wks till the would sloughs & heals

• Secondary haemorrhage

• Delayed return to work

Thus it use is abandoned in current era

Procedures Recommended

Grade – I piles : I.R.C. / Sclerotherapy

Grade – II piles: I.R.C. / R.B.L. / scleroRx

Grade – III piles: Palliative Rx with

R.B.L. / scleroRx

Important Instruction to Doctors

• Piles has a multifactorial causative etiology

• “CURE” should never be promised to any patient

• Just mention that this is the right treatment for your patient under his current circumstances.

• REMOVE FEAR

Open Surgery for Piles

Pre-operative piles Post - operative

There are two established methods of haemorroidectomy

1. Open haemorroidectomy

2. Closed haemorroidectomy

Haemorroidectomy

Breakthrough in Haemorroid SurgeryStapler M.I.P.H

DO’S & DON’T’S (Pathyapathya)

After Kshar sutra procedure patient is asked to follow the below mentioned instructions-

To have balanced (easy to digest) diet.

To avoid Heavy meals.

To avoid suppression of urge and Constipation.

To regularize the food and bowel habits.

To avoid cold beverages, Alcohol and Smoking

Note: All the above mentioned factors are Responsible for Agnimandya and can vitiate the vaat dosh..

To avoid Ratri- jagaran & Day time sleep.

No heavy exercise.

No (over) sex indulgence.

No horse riding (or motor bike/ car- long drive).

To control anger or emotions.

To maintain the local hygiene.

To avoid long time or awkward sitting posture.

• Anal Exercises :- Contraction & relaxation of anus for 5 to 10 minutes in a day will give more strength to anal canal.

• Yogasanas :- Practise of specific yogasanas like Shirshasana, Uttanpadasan will reduce the pressure over the anal mucosa.