Let us speak about piles

Dr Ajit Lukram *

Types of hemorrhoids :: Pix - Wikipedia/ WikipedianProlific and Mikael Häggström

Piles is a very common complaint of patients visiting the doctor. Although piles in medical terminology means haemorrhoids, it has gained popularity as a broad term which includes any discomfort in the anus. Anybody suffering from pain, blood in stool, swelling in and around anus presents to the doctor as ‘piles case’.

We will discuss common diagnosis made in the anus, their presentation, causes, good habits to prevent and treatment modalities in this brief article.

Common diseases in the anorectal region:-

1. Fissure in ano: This is a break in the mucosa lining the anal canal, mostly present in the posterior wall. Patients usually present with very painful bowel movement, spots of blood on stool and tight anus. Most of the time patient gives history of constipation and passing hard stools and occasionally a habit of manual evacuation of stool. Fissure-in-ano is a very common pathology of the anal canal and it can be found associated with other anal pathologies like haemorrhoids, fistula-in-ano, colitis and cancer.

Green leafy vegetables, plenty of fluids, exercise and keeping the stool soft can prevent fissures. Too much of meat and oily food can make the stool hard and give rise to constipation, which can cause fissure in ano.

Fissure in ano can be acute or chronic. They are usually treated with conservative means – local ointments, warm water sitz bath, etc, for first few weeks. Surgical treatment remains the mainstay of treatment for non-healing ulcers and chronic cases not responding to medical treatment.

2. Haemorrhoids - Also known as ‘piles’: Haemorrhoids form the major bulk of complaints in the anal area. Patients having haemorrhoids usually present to the doctor with painless bleeding during bowel movement, splash of fresh red blood on toilet pan, a swelling coming out through the anus during bowel movement. This swelling may go up on pushing up with the hand or may stay outside the anus all the time. Haemorrhoids can be very worry some, if significant bleeding occurs and they may also present to emergency with low blood pressure, anaemia and active bleeding from the anus.

Common causes include chronic straining during bowel movement, constipation, obesity, excessive intake of meat and professions which involve prolonged standing. Rarely it may be the first presentation of bowel cancer.

Good habits to prevent include taking plenty of green leafy vegetables, plenty of fluids orally, exercise and maintaining regular bowel habits with healthy lifestyle and exercise.

They can be treated with a variety of modalities. But before treatment, haemorrhoids are given grades (I, II, III & IV) and according to the grade the treatment modality is carefully chosen.

Low grade haemorrhoids can be attempted to treat with conservative means – warm water sitz bath, local ointments, laxatives and change of diet habits. Pelvic exercises also help. Low grade haemorrhoids not responding to conservative means can be treated with local injections with sclerosants, banding, infra-red coagulation, etc.

Doppler guided haemorrhoidal artery ligation (DG-HAL) is a very clever modality of treating large low grade and high grade haemorrhoids. The feeding vessels to the harmorrhoids are tied through Doppler guidance and subsequently the haemorrhoidal masses shrink. It is a non – invasive procedure.

Conventional open techniques which include excision of the piles (haemorrhoids) is used for high grade and large haemorrhoidal masses and is still widely practiced.

Treatment for Haemorrhoids (Piles)

a) Conservative
b) Injection of sclerosants
c) Infra-red coagulation
d) DG-HAL
e) Banding
f) Stappling
g) Open technique

3. Fistula-in-ano: Patients usually present with chronic discharge of pus from anal canal or surrounding area, pus collection (abscess) around anus. Fistula-in-ano is a channel which communicates the skin surrounding the anus with the mucosa of the anal canal or higher up.

Its causes include abscess formation in the peri-anal region or in the anal mucosa. Passage of hard stool, friction in the anus, local wound, infection, spread of infection in the anal anatomy and finally opening in both skin and anal canal.

Fistula in ano can be treated successfully with surgical techniques which include – fistulectomy, fistulotomy, seton insertion (insertion of thread in fistula), fistula plug, etc.

4. Anorectal cancer: They can present with bleeding per rectum, mass in anal canal or rectum, loss of weight, irregular bowel habits, emaciation, etc. A thorough work up – clinical examination, history, investigations, histopathological diagnosis is indicated before starting treatment. Treatment involves surgery, chemotherapy and radiotherapy.